Pharmacy Prior Authorization Criteria

Basal Insulin - PA, NF

Indications for Prior Authorization

Levemir (insulin detemir)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus.

  Limitations of Use: Levemir is not recommended for the treatment of diabetic ketoacidosis.

Tresiba (insulin degludec)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus.

  Limitations of Use: Not recommended for the treatment of diabetic ketoacidosis.

Semglee (insulin glargine), Semglee (insulin glargine-yfgn), Insulin glargine-yfgn, Rezvoglar (insulin glargine-aglr)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus.

  Limitations of use: Not recommended for the treatment of diabetic ketoacidosis.

Basaglar (insulin glargine)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus.

  Limitations of use: Not recommended for the treatment of diabetic ketoacidosis.

Insulin degludec

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus.

  Limitations of use: Not recommended for the treatment of diabetic ketoacidosis.

Criteria

Levemir, Tresiba

Prior Authorization

Length of Approval: 12 Month(s)

• Diagnosis of diabetes mellitus
AND
• Trial and failure (minimum 30 days supply), contraindication, or intolerance to one of the following:
• Lantus (insulin glargine)
• Toujeo (insulin glargine)

Basaglar, Insulin Glargine, Insulin Glargine-yfgn, Rezvoglar, Semglee

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of diabetes mellitus
AND
• One of the following:
• Both of the following:
• Paid claims or submission of medical records (e.g., chart notes) confirming a minimum duration of 3-month trial of both of the following formulary alternatives:
• Lantus (insulin glargine)
• Toujeo (insulin glargine)
AND
• Submission of medical records (e.g., chart notes) documenting objective information indicating a lack of adequate clinical response to Lantus and Toujeo
OR
• Submission of medical records (e.g., chart notes) documenting ONE of the following:
• An adverse event (e.g., cellulitis) due to treatment with Lantus and Toujeo
• Potential for an allergic reaction due to a non-active ingredient that is contained in Lantus and Toujeo but not included in the requested product
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure (minimum 3 months supply), contraindication, or intolerance to Tresiba (insulin degludec)

Insulin Degludec

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of diabetes mellitus
AND
• One of the following:
• Both of the following:
• Paid claims or submission of medical records (e.g., chart notes) confirming a minimum duration of 3-month trial of Tresiba (insulin degludec)
AND
• Submission of medical records (e.g., chart notes) documenting objective information indicating a lack of adequate clinical response to Tresiba (insulin degludec)
AND
• Submission of medical records (e.g., chart notes) documenting ONE of the following:
• An adverse event (e.g., cellulitis) due to treatment with Tresiba (insulin degludec)
• Potential for an allergic reaction due to a non-active ingredient that is contained in Tresiba (insulin degludec) but not included in the requested product
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure (minimum 3 months supply), contraindication, or intolerance to both of the following:
• Lantus (insulin glargine)
• Toujeo (insulin glargine)

P & T Revisions

1970-01-01, 2026-06-02, 2025-12-18, 2025-06-04, 2024-06-05, 2023-05-25, 2023-02-09, 2022-06-17, 2021-07-06

References

1. Levemir Prescribing Information. Novo Nordisk Inc. Plainsboro, New Jersey. December 2022.
2. Tresiba Prescribing Information. Novo Nordisk Inc. Plainsboro, New Jersey. July 2022.
3. Basaglar Prescribing Information. Eli Lilly and Company. Indianapolis, IN. July 2021.
4. Semglee Prescribing Information. Biocon Biologics Inc. Cambridge, MA. March 2025.
5. Insulin Glargine-yfgn Prescribing Information. Biocon Biologics Inc. Cambridge, MA. March 2025.
6. Rezvoglar Prescribing Information. Eli Lilly and Company. Indianapolis, IN. August 2024.

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Revision History

• 2026-06-02: 2026 UM Annual Review. No clinical criteria changes. Updated guideline name to Basal Inuslin to align with ORx Commercial. Revised non-formulary trial requirement language to align with standard verbiage and updated the required trial duration to 3 months. Background updates
• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-06-04: 2025 Annual Review - no changes
• 2024-06-05: Addition of NF criteria for excluded EHB products
• 2023-05-25: 2023 Annual Review - updated references
• 2023-02-09: Added new Levemir Flexpen formulation to guideline. No changes to criteria.
• 2022-06-17: Annual review: no criteria changes.
• 2021-07-06: New program

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