Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)

Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)

Self-Administration –injectable

The preferred medications are: Humulin

Diagnosis considered for coverage:

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

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:

• 5/17/2022 – New policy approved by P&T

References:

• Humulin R Prescribing Information. Lilly USA, LLC. Indianapolis, IN. November 2019.
• Novolin R Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. November 2019.