Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn, Humalog Tempo, Lyumjev Tempo)

Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn, Humalog Tempo, Lyumjev Tempo)

Self-Administration – injectable

The preferred medications are: Humalog and Lyumjev (Kwikpen or vial)

Diagnosis considered for coverage:

• Admelog
  • Indicated to improve glycemic control in adults and pediatric patients 3 years and older with type 1 diabetes mellitus and adults with type 2 diabetes mellitus
• Apidra
  • Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus
• Fiasp
  • Indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus
• Humalog, Insulin Lispro (Humalog ABA)/Humalog Tempo
  • Indicated to improve glycemic control in adults and children with diabetes mellitus
• Lyumjev/Lyumjev Tempo
  • Indicated to improve glycemic control in adults with diabetes mellitus
• Novolog, Insulin Aspart (Novolog ABA), Novolog ReliOn
  • Indicated to improve glycemic control in adults and pediatric patients 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:
  • Brand Humalog (insulin lispro) KwikPen or vial
  • Lyumjev (insulin lispro) KwikPen or vial

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, hyperglycemia and ketoacidosis due to insulin pump device malfunction

Policy Updates:

• 6/1/2020 – New policy approved by P&T.
• 11/16/2021 – Added Lyumjev as a preferred agent
• 5/17/2022- Insulin class review. Preferred agents updated to Humalog and Lyumjev for rapid-acting insulins, updated criteria for non-preferred agents
• 3/1/2023 - Updating policy to include Humalog Tempo and Lyumjev Tempo

References:

• Admelog Prescribing Information. Sanofi-Aventis U.S. LLC. Bridgewater, NJ. December 2020. 
• Apidra Prescribing Information. Sanofi-Aventis U.S. LLC. Bridgewater, NJ. December 2020. 
• Fiasp Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. December 2019. 
• Humalog Prescribing Information. Lilly USA, LLC. Indianapolis, IN. June 2021. 
• Lyumjev Prescribing Information. Lilly USA, LLC. Indianapolis, IN. August 2021. 
• Novolog Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. August 2021.