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 75-25 VIAL Y    
INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 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 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 HUM/REG INSULIN HM NOVOLIN 70-30 VIAL Y    
INSULIN NPH HUM/REG INSULIN HM HUMULIN 70/30 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 NPH HUMAN ISOPHANE HUMULIN N VIAL Y    
INSULIN REGULAR, HUMAN HUMULIN R VIAL Y    
INSULIN REGULAR, HUMAN HUMULIN R U-500 VIAL Y    
INSULIN REGULAR, HUMAN HUMULIN R VIAL Y    
INSULIN REGULAR, HUMAN NOVOLIN R VIAL Y    
INSULIN REGULAR, HUMAN NOVOLIN R VIAL Y    
INSULIN ZINC HUMAN RECOMBINANT NOVOLIN L VIAL Y    
INSULIN DEGLUDEC TRESIBA FLEXTOUCH U-100 INSULN PEN N PA Document Mar 31, 2016
INSULIN DEGLUDEC TRESIBA FLEXTOUCH U-200 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 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 KWIKPEN U-100 INSULN PEN N PA Document  
INSULIN LISPRO HUMALOG KWIKPEN U-200 INSULN PEN N PA Document  
INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25 KWIKPEN INSULN PEN N PA Document  
INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 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