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Drug - Insulin

June 2019

Therapeutic area - Diabetes

Preferred Nonpreferred
Humalog (insulin lispro) vial
Humalog mix (50/50 or 75/25) (insulin lispro protamine/insulin lispro) vial
Humulin R (regular insulin) 500 units/mL vial
Humulin 70/30 (insulin NPH human isophane/regular insulin) vial
Humulin N (insulin isophane) vial
Humulin R (regular insulin) vial
Lantus (insulin glargine)
Levemir (insulin detemir)
Novolin 70/30 (insulin isophane/regular insulin) vial
Novolin N (insulin isophane) vial
Novolin R (regular insulin)
Novolog (insulin aspart)
Novolog Mix 70/30 (insulin aspart protamine/insulin aspart)
Admelog (insulin lispro)
Afrezza (regular insulin) inhalation
Apidra (insulin glulisine)
Basaglar (insulin glargine)*
Fiasp/Fiasp Touch (insulin aspart (niacinamide))
Humalog (insulin lispro) 200 units/mL pen
Humalog (insulin lispro) cartridge
Humalog (insulin lispro) Junior Kwikpen
Humalog (insulin lispro) pen
Humalog Mix 50/50 or 75/25 (insulin lispro protamine/insulin lispro) pen
Humulin R 500 units/mL (regular insulin) pen
Humulin 70/30 (insulin isophane/regular insulin) pen
Humulin N (insulin NPH human isophane) pen
Insulin lispro
Novolin 70/30 (insulin isophane/regular insulin) pen
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


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


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

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