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.
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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
insulin glargine,hum.rec.anlog LANTUS SOLOSTAR INSULN PEN Y   N  
insulin lispro HUMALOG CARTRIDGE Y   N  
insulin lispro HUMALOG JUNIOR KWIKPEN INS PEN HF Y   N  
insulin lispro HUMALOG KWIKPEN U-200 INSULN PEN Y   N  
insulin lispro INSULIN LISPRO KWIKPEN U-100 INSULN PEN Y   N  
insulin lispro INSULIN LISPRO VIAL Y   N  
insulin lispro HUMALOG VIAL Y   N  
insulin lispro protamin/lispro HUMALOG MIX 75-25 VIAL Y   N  
insulin NPH hum/reg insulin hm NOVOLIN 70-30 FLEXPEN INSULN PEN Y Pharmacy PA N  
insulin NPH hum/reg insulin hm NOVOLIN 70-30 INNOLET INSULN PEN Y Pharmacy PA N  
insulin NPH hum/reg insulin hm HUMULIN 70-30 VIAL Y Pharmacy PA N  
insulin NPH hum/reg insulin hm NOVOLIN 70-30 VIAL Y Pharmacy PA N  
insulin NPH human isophane HUMULIN N VIAL Y   N  
insulin regular, human HUMULIN R U-500 VIAL Y   N  
insulin regular, human NOVOLIN R VIAL Y   N  
insulin regular, human NOVOLIN R VIAL Y   N  
insulin regular, human HUMULIN R VIAL Y   N  
insulin aspart INSULIN ASPART PENFILL CARTRIDGE N Pharmacy PA N  
insulin aspart NOVOLOG VIAL N Pharmacy PA N  
insulin aspart (niacinamide) FIASP PENFILL CARTRIDGE N Pharmacy PA N  
insulin aspart (niacinamide) FIASP VIAL N Pharmacy PA N  
insulin aspart prot/insuln asp NOVOLOG MIX 70-30 FLEXPEN INSULN PEN N Pharmacy PA N  
insulin aspart prot/insuln asp INSULIN ASPART PROT MIX 70-30 VIAL N Pharmacy PA N  
insulin aspart-szjj MERILOG VIAL N Pharmacy PA N  
insulin aspart-xjhz KIRSTY VIAL N Pharmacy PA N  
insulin degludec TRESIBA FLEXTOUCH U-100 INSULN PEN N Pharmacy PA N Mar 31, 2016
insulin degludec INSULIN DEGLUDEC PEN (U-200) INSULN PEN N Pharmacy PA N  
insulin degludec TRESIBA VIAL N Pharmacy PA N  
insulin degludec INSULIN DEGLUDEC VIAL N Pharmacy PA N  
insulin degludec/liraglutide XULTOPHY 100-3.6 INSULN PEN N Pharmacy PA N  
insulin detemir LEVEMIR FLEXPEN INSULN PEN N Pharmacy PA N  
insulin glargine-aglr REZVOGLAR KWIKPEN INSULN PEN N Pharmacy PA N  
insulin glargine-yfgn INSULIN GLARGINE-YFGN INSULN PEN N Pharmacy PA N  
insulin glargine,hum.rec.anlog BASAGLAR KWIKPEN U-100 INSULN PEN N Pharmacy PA N  
insulin glargine,hum.rec.anlog INSULIN GLARGINE SOLOSTAR INSULN PEN N Pharmacy PA N  
insulin glargine,hum.rec.anlog TOUJEO SOLOSTAR INSULN PEN N Pharmacy PA N  
insulin glargine,hum.rec.anlog INSULIN GLARGINE VIAL N Pharmacy PA N  
insulin glulisine APIDRA VIAL N Pharmacy PA N  
insulin lispro ADMELOG VIAL N Pharmacy PA N  
insulin lispro-aabc LYUMJEV TEMPO PEN U-100 INSULN PEN N Pharmacy PA N  
insulin NPH human isophane HUMULIN N KWIKPEN INSULN PEN N Pharmacy PA N  
insulin NPH human isophane NOVOLIN N FLEXPEN INSULN PEN N Pharmacy PA N  
insulin regular, human AFREZZA CART INHAL N Pharmacy PA N Sep 23, 2014
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