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Insulin

Drug - Insulin

February 2018

Therapeutic area - Diabetes

Preferred Nonpreferred
Lantus (insulin glargine) Apidra (insulin glulisine) PA
Levemir (insulin detemirl) Humalog (insulin lispro) PA
Novolin 70/30 (insulin isophane/regular insulin) Basaglar (insulin glargine) PA
Fiasp/Fiasp Touch 
Novolin N (insulin isophane) Humalog Mix 50/50 (insulin lispro protamine/insulin lispro) PA
Novolin R (regular insulin) Humalog Mix 75/25 (nsulin lispro protamine/insulin lispro) PA
Novolog (insulin aspart) Humulin 70/30 (insulin isophane/regular insulin) PA
Novolog Mix 70/30 (insulin aspart protamine/insulin aspart) Humulin N (insulin isophane) PA
Relion 70/30 (insulin isophane/regular insulin) Humulin R (regular insulin) PA
Relion N (insulin isophane) Humulin R-500 (regular insulin) PA
Soliqua (insulin glargine and lixisenatide) PA**
Toujeo (insulin glargine) PA
Tresiba (insulin degludec) PA
Xultophy (insulin degludec and liraglutide) PA**

*Basaglar is under separate PA criteria sheet. See PA criteria sheet, “Basaglar”.

** Soliqua and Xultophy are under separate PA criteria sheet. See PA criteria sheet, “Basal insulin and GLP-1-receptor agonist combination

Approval criteria for nonpreferred insulin

  • Patient is allergic to a preferred comparable insulin OR
  • Patient has an inadequate response to a preferred comparable insulin but has had a demonstrated adequate response to the non-preferred insulin

Exceptions

See Grandfathering Criteria – which indicate patient specific criteria that would exclude a patient from switching to a preferred insulin.

Pregnancy

Both Novolog and Humalog are approved for use in pregnancy. Novolog is the preferred analog insulin.

Note

  • Humalog vials, Humalog Mix 50-50 vials, Humalog Mix 75-25 vials and Humulin 70-30 vials do not require prior authorization
  • All other Humulin and Humalog products and dosage forms require prior authorization

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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