WHA
 

Short Acting Insulin - ST, NF

Indications for Prior Authorization

Humalog (insulin lispro)
  • For diagnosis of Diabetes Mellitus
    Indicated to improve glycemic control in adults and children with diabetes mellitus.

Lyumjev (insulin lispro-aabc)
  • For diagnosis of Diabetes Mellitus
    Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus.

Novolog (insulin aspart)
  • For diagnosis of Diabetes Mellitus
    Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus.

Novolin (human insulin)
  • For diagnosis of Diabetes Mellitus
    Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus.

Kirsty (insulin aspart-xjhz)
  • For diagnosis of Diabetes Mellitus
    Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus.

Criteria

Humalog Tempo Pen, Kirsty, Lyumjev Tempo Pen

Step Therapy

Length of Approval: 12 Month(s)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • Trial and failure (of a minimum 30 day supply), contraindication, or intolerance to two of the following:
    • Brand Humalog (insulin lispro) or Brand Insulin lispro
    • Brand Novolog (insulin aspart)
    • Lyumjev (insulin lispro)
    • Admelog (insulin lispro)
    • Apidra (insulin glulisine)
    • Fiasp (insulin aspart)
    • Merilog (insulin aspart-szjj)
Kirsty, Novolog Relion, Novolog Flexpen Relion, Novolog Mix 70/30 Relion, Novolog Mix 70/30 Flexpen Relion

Non Formulary

Length of Approval: 12 Month(s)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • One of the following:
    • Both of the following:
      • Paid claims or submission of medical records (e.g., chart notes) confirming a minimum 3-month trial of Novolog/Novolog mix (insulin aspart), Merilog (insulin aspart-szjj), AND Fiasp (insulin aspart)
        • AND
      • Submission of medical records (e.g., chart notes) documenting objective information indicating a lack of adequate clinical response to Novolog/Novolog mix (insulin aspart), Merilog (insulin aspart-szjj), AND Fiasp (insulin aspart)
      OR
    • Submission of medical records (e.g., chart notes) documenting ONE of the following:
      • An adverse event (e.g., cellulitis) due to treatment with Novolog/Novolog mix (insulin aspart), Merilog (insulin aspart-szjj), AND Fiasp (insulin aspart)
      • Potential for an allergic reaction due to a non-active ingredient that is contained in Novolog/Novolog mix (insulin aspart), Merilog (insulin aspart-szjj), AND Fiasp (insulin aspart) but not included in the requested product
    AND
  • Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure (of a minimum 30 day supply), contraindication, or intolerance to three of the following:
    • Brand Humalog (insulin lispro) or Brand Insulin lispro
    • Lyumjev (insulin lispro)
    • Admelog (insulin lispro)
    • Apidra (insulin glulisine)
Novolin R Relion, Novolin N Relion, Novolin 70/30 Relion

Non Formulary

Length of Approval: 12 Month(s)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • One of the following:
    • Both of the following:
      • Paid claims or submission of medical records (e.g., chart notes) confirming a minimum 3-month trial of Novolin/Novolin mix (human insulin) AND Humulin/Humulin mix (human insulin)
        • AND
      • Submission of medical records (e.g., chart notes) documenting objective information indicating a lack of adequate clinical response to Novolin/Novolin mix (human insulin) AND Humulin/Humulin mix (human insulin)
      OR
    • Submission of medical records (e.g., chart notes) documenting ONE of the following:
      • An adverse event (e.g., cellulitis) due to treatment with Novolin/Novolin mix (human insulin) AND Humulin/Humulin mix (human insulin)
      • Potential for an allergic reaction due to a non-active ingredient that is contained in Novolin/Novolin mix (human insulin) AND Humulin/Humulin mix (human insulin) but not included in the requested product

  • Guideline ID
    GL-508201

  • Formulary
    Premium

  • Effective date
    Mar 1, 2026

  • P&T approval date
    Aug 2, 2004

P & T Revisions

2026-02-20, 2025-12-18, 2025-12-18, 2025-08-28, 2025-06-04, 2024-06-03, 2023-11-29, 2023-11-22, 2023-11-15, 2023-10-27, 2023-09-06, 2023-08-02, 2023-05-23, 2023-01-06, 2022-06-01, 2022-04-29, 2022-03-10, 2022-02-03, 2021-07-19, 2021-05-24, 2020-10-28, 2020-08-20, 2020-05-29, 2020-04-17, 2020-03-18, 2020-01-27, 2019-12-17, 2019-10-17

  1. Novolog Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. December 2023.
  2. Humalog Prescribing Information. Lilly USA, LLC. Indianapolis, IN. May 2025.
  3. Novolin Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. November 2022.
  4. Lyumjev Prescribing Information. Lilly USA, LLC. Indianapolis, IN. October 2022.
  5. Kirsty Prescribing Information. Biocon Biologics Inc. Cambridge, MA. July 2025.
  • 2026-02-20: 2026 UM Annual Review. Term ST on Merilog and add Merilog as a step 1 option to the existing Short-Acting Insulin ST. Update verbiage for NF criteria to align with biosimilar verbiage, to include paid claims or submission of medical records confirming trial of preferred drugs, objective information indicating a lack of adequate control on preferred drugs OR adverse event with treatment with preferred or allergic reaction due to non-active ingredient in preferred drugs.
  • 2025-12-18: No criteria changes
  • 2025-12-18: no criteria changes, added IL statute operational note
  • 2025-08-28: update guideline
  • 2025-06-04: 2025 Annual Review - updated references
  • 2024-06-03: 2024 UM Annual Review. Updated NF criteria for Novolog and Novolin products.
  • 2023-11-29: Addition of Brand Insulin lispro as a preferred alternative
  • 2023-11-22: Updated guideline effective date to 1/1/24.
  • 2023-11-15: Updated guideline
  • 2023-10-27: Program update to remove Admelog, Apidra, Fiasp, Novolog, Novolin as targets.
  • 2023-09-06: update guideline
  • 2023-08-02: Added Novolog Penfill to NF criteria
  • 2023-05-23: Removed Novolog products from ST guideline as they were moved to ABA PA guideline.
  • 2023-01-06: Added Humalog & Lyumjev tempo pen to mirror Admelog criteria. Updated lyumjev indication section and references.
  • 2022-06-01: Annual review: No criteria changes, updated references.
  • 2022-04-29: GPI Reclassification
  • 2022-03-10: Updated GL name to include "-ST, NF"
  • 2022-02-03: Added NF criteria for excluded insulin products. Updated references and background.
  • 2021-07-19: Update to add Novolog Relion products as targets
  • 2021-05-24: Annual review: updated references
  • 2020-10-28: Lyumjev moving to preferred.
  • 2020-08-20: insulin step to include Lyumjev as a step target
  • 2020-05-29: Annual review, no changes to clinical criteria updated references. 5.29..2020 - updated new GPI in products section (added GPI 2710400500D2222)
  • 2020-04-17: Added Insulin lispro junior (ABA for Humalog Jr) and insulin lispro protamine 75/25 (ABA for Humalog Mixpen) as targets to the step.
  • 2020-03-18: updated reference
  • 2020-01-27: Modified indication and references section due to updated indication (To improve glycemic control in adult and pediatric patients with diabetes mellitus.) No criteria changes
  • 2019-12-17: Added insulin aspart, the ABA for Novolog to bucket with ABA insulin lispro & added Brand before the word novolog for bucket that has insulin aspart
  • 2019-10-17: New Penfil 100/mL cartridge. Add as a target in the short-acting insulin ST guideline to the section that requires both Humalog AND Novolog.