Pharmacy Prior Authorization Criteria

Awiqli (insulin icodec-abae)

Indications for Prior Authorization

Awiqli (insulin icodec-abae)

• For diagnosis of Type 2 diabetes mellitus
  Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Criteria

Awiqli

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of Type 2 Diabetes Mellitus
AND
• Patient is 18 years of age or older
AND
• Inadequate glycemic control on non-insulin antidiabetic therapy (i.e., HbA1c greater than or equal to 7%)
AND
• One of the following:
• Trial and inadequate response (minimum 90-day supply) or contraindication to one of the following basal insulin:
• Lantus (insulin glargine)
• Toujeo (insulin glargine)
• Basaglar Kwikpen (insulin glargine)
• Rezvoglar Kwikpen (insulin glargine)
• Tresiba (insulin degludec)
OR
• Patient has a barrier that prevents safe self-administration of daily insulin (e.g., non-adherence to daily basal insulin, visual impairment, need for caregiver assistance, physical or cognitive limitations, etc)
AND
• Patient or caregiver has been counseled on all of the following:
• Once weekly administration
• Risk, recognition, and management of hypoglycemia
• Not to be used in combination with any other basal insulin

Awiqli

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., decrease in HbA1c from baseline)

P & T Revisions

2026-07-14, 2026-07-14

References

1. Awiqli Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. March 2026.

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Revision History

• 2026-07-14: New Program for Awiqli
• 2026-07-14: New Program for Awiqli

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