Diabetes, Insulins

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
insulin aspart NOVOLOG CARTRIDGE Y    
insulin aspart NOVOLOG FLEXPEN INSULN PEN Y    
insulin aspart NOVOLOG VIAL Y    
insulin aspart prot/insuln asp NOVOLOG MIX 70-30 FLEXPEN INSULN PEN Y    
insulin aspart prot/insuln asp NOVOLOG MIX 70-30 VIAL Y    
insulin detemir LEVEMIR FLEXTOUCH INSULN PEN Y PA Document  
insulin glargine,hum.rec.anlog LANTUS SOLOSTAR INSULN PEN Y PA Document  
insulin glargine,hum.rec.anlog LANTUS VIAL Y    
insulin lispro HUMALOG VIAL Y    
insulin lispro protamin/lispro HUMALOG MIX 50-50 VIAL Y    
insulin lispro protamin/lispro HUMALOG MIX 75-25 VIAL Y    
insulin NPH hum/reg insulin hm HUMULIN 70/30 KWIKPEN INSULN PEN Y PA Document  
insulin NPH hum/reg insulin hm NOVOLIN 70-30 INNOLET INSULN PEN Y PA Document  
insulin NPH hum/reg insulin hm NOVOLIN 70-30 VIAL Y    
insulin NPH hum/reg insulin hm HUMULIN 70-30 VIAL Y    
insulin NPH hum/reg insulin hm HUMULIN 70-30 VIAL Y    
insulin NPH hum/reg insulin hm NOVOLIN 70-30 VIAL Y    
insulin NPH hum/reg insulin hm HUMULIN 70/30 VIAL Y    
insulin NPH human isophane HUMULIN N VIAL Y    
insulin NPH human isophane NOVOLIN N VIAL Y    
insulin NPH human isophane HUMULIN N VIAL Y    
insulin NPH human isophane NOVOLIN N VIAL Y    
insulin regular, human HUMULIN R U-500 VIAL Y    
insulin regular, human NOVOLIN R VIAL Y    
insulin regular, human HUMULIN R VIAL Y    
insulin regular, human HUMULIN R VIAL Y    
insulin regular, human NOVOLIN R VIAL Y    
insulin zinc human recombinant NOVOLIN L VIAL Y    
insulin aspart (niacinamide) FIASP FLEXTOUCH INSULN PEN N PA Document  
insulin aspart (niacinamide) FIASP VIAL N    
insulin degludec TRESIBA FLEXTOUCH U-200 INSULN PEN N PA Document Mar 31, 2016
insulin degludec TRESIBA FLEXTOUCH U-100 INSULN PEN N PA Document Mar 31, 2016
insulin degludec/liraglutide XULTOPHY 100-3.6 INSULN PEN N    
insulin detemir LEVEMIR VIAL N    
insulin glargine,hum.rec.anlog TOUJEO MAX SOLOSTAR INSULN PEN N PA Document  
insulin glargine,hum.rec.anlog BASAGLAR KWIKPEN U-100 INSULN PEN N PA Document  
insulin glargine,hum.rec.anlog TOUJEO SOLOSTAR INSULN PEN N PA Document  
insulin glargine/lixisenatide SOLIQUA 100-33 INSULN PEN N    
insulin glulisine APIDRA SOLOSTAR INSULN PEN N PA Document  
insulin glulisine APIDRA VIAL N    
insulin lispro HUMALOG CARTRIDGE N PA Document  
insulin lispro HUMALOG JUNIOR KWIKPEN INS PEN HF N    
insulin lispro ADMELOG SOLOSTAR INSULN PEN N PA Document  
insulin lispro HUMALOG KWIKPEN U-200 INSULN PEN N PA Document  
insulin lispro HUMALOG KWIKPEN U-100 INSULN PEN N PA Document  
insulin lispro ADMELOG VIAL N    
insulin lispro protamin/lispro HUMALOG MIX 50-50 KWIKPEN INSULN PEN N PA Document  
insulin lispro protamin/lispro HUMALOG MIX 75-25 KWIKPEN INSULN PEN N PA Document  
insulin NPH human isophane HUMULIN N KWIKPEN INSULN PEN N PA Document  
insulin regular, human AFREZZA CART INHAL N   Sep 23, 2014
insulin regular, human HUMULIN R U-500 KWIKPEN INSULN PEN N PA Document