INSULIN
UTILIZATION MANAGEMENT CRITERIA
DRUG CLASS:
Insulin
BRAND (generic) NAMES:
Rapid-Acting Insulins
NovoLog (insulin aspart)*
Humalog (insulin lispro)
Apidra (insulin glulisine)
Afrezza (insulin human)
Short
Short-Acting Insulins
Novolin R*
Humulin R
Humulin R U
U-500
Intermediate-Acting Insulins
Novolin N*
Humulin N
NPH-Regular Combinations
Novolin 70/30*
Humulin 70/30
NPH
NPH-Lispro Combinations
Humalog Mix 75/25
Humalog Mix 50/50
NPH – Novolog Combination
NovoLog Mix 70/30*
70/30
*Preferred insulin products.
FDA-APPROVED
APPROVED INDICATIONS:
Humalog (insulin lispro), NovoLog (insulin aspart)
aspart), Apidra (insulin glulisine)
• Treatment of patients with Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus for the control
of hyperglycemia.
Humulin R, Novolin R
• For the treatment of Type 1 Diabetes Mellitus or Type 2 Diabetes Mellitus inadequately managed
by diet, exercise, and oral hypoglycemics.
• For the treatment of gestational diabetes or for the treatment of patients with pre-existing
pre
diabetes
mellitus (Type 1 Diabetes Mellitus or Type 2 Diabetes Mellitus) who are now pregnant: for
pregnant patients with gestational
gestational-onset diabetes not controlled by diet-therapy
therapy alone.
• For the treatment of diabetic ketoacidosis.
• For the treatment of hyper-osmolar
osmolar hyperglycemic state in patients with Type 2 Diabetes Mellitus.
Humulin N, Novolin N
• For the treatment of Type 1 Diabetes
iabetes Mellitus or Type 2 Diabetes Mellitus inadequately managed
manag
by diet, exercise, and oral hypoglycemics.
• For the treatment of gestational diabetes or for the treatment of patients with preexisting Type 1
Diabetes Mellitus or Type 2 Diabetes Mellitus who are now pregnant.
Novolin 70/30, Humulin 70/30
• For the treatment of Type 1 Diabetes Mellitus or for Type 2 Diabetes Mellitus inadequately
managed by diet, exercise, and oral hypoglycemics.
Originated: January 2015
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Humalog Mix 75/25, Humalog Mix 50/50
• For the treatment of Type 1 Diabetes Mellitus or for Type 2 Diabetes Mellitus inadequately
managed by diet, exercise, and oral hypoglycemics.
NovoLog Mix 70/30
• Improve glycemic control in patients with Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus.
Afrezza
• Improve glycemic control in patients with Diabetes Mellitus.
COVERAGE AUTHORIZATION CRITERIA
Nonpreferred insulin products may be eligible for coverage when:
1. If the request is for Humulin U-500 then:
a. The patient is currently receiving Humulin U-500; OR
b. The patient is not currently receiving Humulin U-500 and requires more than 200 units
of insulin per day.
2. If the request is for Humalog Mix 50/50 then:
a. The patient is currently receiving Humalog Mix 50/50 AND the prescriber states the
patient is at risk of losing good control if switched to a different insulin; OR
b. The patient is not currently receiving Humalog Mix 50/50 AND the prescriber states
that the patient has tried and failed a preferred insulin mix (Novolin 70/30, NovoLog
Mix 70/30).
3. If the request is for Afrezza, Apidra, Humalog, Humulin R, Humulin N, Humulin 70/30, and/or
Humalog Mix 75/25 then:
a. The patient has a documented adverse reaction, intolerance or FDA labeled
contraindication to preferred insulin (Novolin, NovoLog) products.
DOSAGE AND ADMINISTRATION:
Dosing must be individualized. The total daily insulin requirement may vary and is usually
between 0.5 and 1.0 unit/kg/day.
REFERENCES:
1.
2.
3.
4.
5.
Humalog (insulin lispro injection [rDNA origin] solution for subcutaneous injection). Eli Lilly
and Company. November 2013.
Novolog (insulin aspart [rDNA origin] injection) solution for subcutaneous use. Novo
Nordisk, Inc. April 2014.
Apidra (insulin glulisine [rDNA origin] injection) solution for injection. Sanofi-Aventis. May
2014.
Humulin R (insulin human injection [rDNA origin]) solution for subcutaneous injection. Eli
Lilly and Company. March 2013.
Novolin R (human insulin injection [rDNA origin]). Novo Nordisk, Inc. March 2013.
Originated: January 2015
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6.
7.
8.
9.
10.
11.
12.
13.
Humulin N (insulin [rDNA origin] isophane suspension). Eli Lilly and Company. November
2013.
Novolin N (human insulin isophane suspension injection) suspension. Novo Nordisk.
March 2013.
Novolin 70/30 (70% NPH, Human Insulin Isophane Suspension and 30% Regular, Human
Insulin Injection, [rDNA]). Novo Nordisk. March 2013.
Humulin 70/30 (70% human insulin isophane suspension and 30% human insulin injection
(rDNA origin). Eli Lilly and Company. November 2013.
Humalog Mix 75/25 (75% insulin lispro protamine suspension and 25% insulin lispro
injection (rDNA origin). Eli Lilly and Company. November 2013.
Humalog Mix 50/50 (50% insulin lispro protamine suspension and 50% insulin lispro
injection [rDNA origin]). Eli Lilly and Company. November 2013.
NovoLog 70/30 (70% insulin aspart protamine suspension and 30% insulin aspart
injection. Novo Nordisk Inc. March 2013.
Afrezza (insulin human) Prescribing Information. MannKind Corporation. June 2014.
Originated: January 2015
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