Insulin, Long-Acting (e.g., Basaglar, Levemir, Tresiba)

SELF ADMINISTRATION - INJECTABLE

The Preferred Medications are Lantus, Toujeo Solostar, and Toujeo Max Solostar

Indications for Prior Authorization:

  • Basaglar: Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus.  Not recommended for treating diabetic ketoacidosis.
  • Levemir: Indicated to improve glycemic control in adults and chldren with diabetes mellitus.  Not recommended for treating diabetic ketoacidosis.
  • Tresiba: Indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus.  Not recommended for treateing diabetic ketoacidosis.  Not recommended for pediatric patients requiring less than 5 units of Tresiba.

Patients must meet the following criteria for the indications above:

  • Patient has tried and failed Lantus, Toujeo Solostar, and Toujeo Max Solostar, OR
  • Medical record documentation supports a medically appropriate reason why the preferred medications cannot be considered, AND
  • For Tresiba: patient is 1 year of age or older and does not require less than 5 units of Tresiba

Approval:

  • 1 year