Pharmacy Prior Authorization Criteria

Symlin (pramlintide acetate injection)

Indications for Prior Authorization

Symlin (pramlintide acetate)

• For diagnosis of Type 1 Diabetes Mellitus
  Indicated as an adjunctive treatment in patients with type 1 diabetes who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy.

• For diagnosis of Type 2 Diabetes Mellitus
  Indicated as an adjunctive treatment in patients with type 2 diabetes who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy.

Criteria

Symlin

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• One of the following diagnoses:
• Type 1 diabetes
• Type 2 diabetes
AND
• Patient has failed to achieve desired glucose control despite optimal insulin therapy
AND
• Patient is taking concurrent mealtime insulin therapy (e.g., Humulin, Humalog, Novolin, Novolog)

Symlin

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient has experienced an objective response to therapy demonstrated by an improvement in HbA1c from baseline
AND
• Patient is receiving concurrent mealtime insulin therapy (e.g., Humulin, Humalog, Novolin, Novolog)

P & T Revisions

2024-07-30, 2023-07-03, 2021-07-01

References

1. Symlin Prescribing Information. Amylin Pharmaceuticals, Inc. Wilmington, DE. December 2019.

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Revision History

• 2024-07-30: Annual review: No criteria changes.
• 2023-07-03: Annual review: No criteria changes.
• 2021-07-01: Annual review: no criteria changes

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