Pharmacy Prior Authorization Criteria

Emergency Agents for the Treatment of Severe Hypoglycemia - ST, NF

For diagnosis of Severe Hypoglycemia
Indicated for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes.
For diagnosis of Diagnostic Aid
GlucaGen is indicated as a diagnostic aid for use during radiologic examinations to temporarily inhibit movement of the gastrointestinal tract in adult patients.

For diagnosis of Severe Hypoglycemia
Indicated for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes mellitus.
For diagnosis of Diagnostic Aid
Indicated as a diagnostic aid for use during radiologic examinations to temporarily inhibit movement of the gastrointestinal tract in adult patients.

For diagnosis of Severe Hypoglycemia
Indicated for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes ages 2 years and above.

Step Therapy

Length of Approval: 12 Month(s)

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Trial and failure within the past 180 days, or intolerance to one of the following preferred drugs:

Non Formulary

Length of Approval: 12 Month(s)

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure within the past 180 days, or intolerance to one of the following preferred drugs:

2025-02-05, 2024-02-01, 2023-01-04, 2022-10-18, 2022-03-26, 2022-01-04, 2021-09-29, 2021-06-01, 2020-12-14, 2019-12-30

GlucaGen Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. March 2021.
Glucagon Prescribing Information. Lilly USA, LLC. Indianapolis, IN. January 2021.
Gvoke Prescribing Information. Xeris Pharmaceuticals, Inc. Chicago IL. December 2023.

2025-02-05: 2025 Annual Review. No criteria changes.
2024-02-01: No criteria changes. Updated References.
2023-01-04: Annual review: No criteria changes. Updated references and background.
2022-10-18: Criteria update without changing clinical intent.
2022-03-26: Updated GL name to include "ST, NF"
2022-01-04: Annual Review and Formulary strategy update. Preferred Agents: Trial of one out of Baqsimi, Fresenius’ Glucagon Kit, Zegalogue, generic glucagon kit. Non-Preferred/Step Targets: Lilly’s Glucagon Kit, Novo’s Glucagen, Gvoke. NP will also be excluded on Premium, added NF section with documentation for trials. Updated references.
2021-09-29: ST removed from Zegalogue, updated GL to remove Zegalogue as a target.
2021-06-01: Added Zegalogue as a target drug to the existing Glucagen ST, updated background/references
2020-12-14: Annual review, no updates to clinical criteria
2019-12-30: Added ST for Glucagen to step through one of these preferred products (Glucagon, Gvoke, Baqsimi) eff. 7/1/20 for Select and Premium.