Insulin Long-Acting (Basaglar, Basaglar Tempo, Levemir, Semglee, Brand Insulin Glargine-yfgn, Rezvoglar, Insulin Degludec [Tresiba and Tresiba ABA], Insulin Glargine [Lantus ABA, Toujeo ABA])

Insulin Long Acting (Basaglar, Basaglar Tempo, Levemir, Semglee, Brand Insulin Glargine-yfgn, Rezvoglar, Insulin Degludec [Tresiba and Tresiba ABA], Insulin Glargine [Lantus ABA, Toujeo ABA])

Self-Administration –injectable

Preferred agents: Lantus, Toujeo

Diagnosis considered for coverage:

• Basaglar

  • Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus

• Basaglar Tempo

  • Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus

• Insulin glargine

  • Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus

• brand Insulin Glargine (Lantus ABA and Toujeo ABA)

  • Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus

• Levemir

  • Indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus

• Semglee

  • Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus

• Rezvoglar

  • Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus

  • Limitations of Use:

    • Not recommended for treating diabetic ketoacidosis

• Insulin degludec (Tresiba and Tresiba ABA)

  • Indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus

Coverage Criteria:

For diagnosis of diabetes mellitus:

• 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 to a minimum 30-day supply, contraindication, or intolerance to both of the following:

  • Lantus (insulin glargine)

  • Toujeo (insulin glargine)

• Request for nonpreferred brand insulin glargine products (Lantus ABA and Toujeo ABA): Please indicate medical reason why the following agents cannot be used: Lantus (insulin glargine) and Toujeo (insulin glargine) 

Reauthorization Criteria:

For diagnosis of diabetes mellitus:

• Patient has experienced a positive clinical response to therapy

Coverage Duration: 

• Initial: 1 year

• Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

• Contraindicated during episodes of hypoglycemia 

• Never share needles or syringes between patients

• Additional warnings for hyperglycemia or hypoglycemia with changes in insulin regimen, hypoglycemia, hypoglycemia due to medication errors, hypersensitivity and allergic reactions, hypokalemia, fluid retention, and heart failure with concomitant use of PPAR-gamma agonists

Policy Updates:

• 03/18/2020 – New policy approved by P&T for Basaglar

• 02/16/2021 – New policy approved by P&T for Semglee

• 05/17/2022- Insulin class review. Preferred agents updated to Lantus and Toujeo for long-acting insulins, updated criteria for non-preferred agents

• 03/01/2023 - Updating policy to include Basaglar Tempo pen

• 06/01/2023 - Updating policy to include Rezvoglar

References:

• Basaglar Prescribing Information. Lilly USA, LLC. Indianapolis, IN. July 2021. 

• Garber AJ, Abrahamson MJ, Barzilay JI, et al. American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive diabetes management algorithm – 2018 executive summary. https://www.aace.com/sites/all/files/diabetes-algorithm-executive-summary.pdf. Accessed May 27,2020. 

• Insulin glargine-yfgn prescribing information. Mylan Specialty, Morgantown, WV. July 2021. 

• Lantus Prescribing Information. Sanofi-Aventis U.S. LLC. Bridgewater, NJ. January 2021.

• Levemir Prescribing Information. Novo Nordisk A/S. Bagsvaerd, Denmark. March 2020. 

• Semglee Prescribing Information. Mylan Specialty, Morgantown, WV. June 2020. 

• Toujeo Prescribing Information. Sanofi-Aventis U.S. LLC. Bridgewater, NJ. December 2020.

• Rezvoglar Prescribing Information. Eli Lilly and Company. Indianapolis, IN. December 2021.

• Tresiba Prescribing Information. Novo Nordisk A/S. Bagsvaerd, Denmark. November 2019.