Insulin

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