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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAdvanced Health Insulin Prior Auth | OpenPayer
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    CurrentAdvanced HealthPolicy N/A

    Non-Preferred Insulin Drug Use Criteria

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    This policy governs prior authorization for non-preferred insulin products. Coverage is available when the member has failed or cannot use a preferred formulary insulin, or when documentation supports why a preferred product cannot be used.

    Policy Summary
    PayerAdvanced Health
    PolicyNon-Preferred Insulin Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument failure, contraindication, or inability to use a preferred formulary insulin when requesting a non-preferred insulin.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsMaximum approval period when criteria are met
    2 pathwaysQualifying routes for non-preferred insulin approval
    Formulary firstPreferred formulary insulin requirement
    No PAUnbranded biosimilar insulin products on formulary

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria

    Initial request

    Covered when at least one qualifying pathway is met.

    Qualifying exception to preferred formulary insulin

    • Preferred product failure or contraindication: The member has trialed and failed a preferred formulary product, or has a contraindication to a preferred formulary product.

      Approve for up to 12 months.

    • Documented inability to use preferred product: Documentation explains why a preferred formulary product cannot be used.

      Examples include some insulin pumps requiring brand Humalog or Novolog. Approve for up to 12 months.

    Use of a non-preferred insulin does not meet coverage criteria when the member has not trialed and failed an appropriate preferred formulary insulin, has no contraindication to a preferred product, and there is no documentation explaining why a preferred product cannot be used. In these circumstances, the request is denied and an appropriate formulary alternative should be trialed.

    Provider Actions

    Prior Authorization

    Prior Authorization Required for Non-Preferred Insulin

    Submit prior authorization for a non-preferred insulin. Approval may be granted for up to 12 months when the member meets an exception criterion.

    • The member has trialed and failed a preferred formulary product or has a contraindication to one; or
    • There is documentation explaining why an appropriate preferred formulary product cannot be used.
    Step Therapy

    Preferred Insulin Must Be Used First

    Use a preferred formulary insulin as first-line therapy unless a documented exception applies. This requirement promotes use of the least costly appropriate insulin therapy.

    • If an exception is established, the non-preferred insulin may be approved for up to 12 months.
    Documentation Required

    Required Exception Documentation

    Document the specific exception supporting non-preferred insulin use. Acceptable documentation must show a trial and failure, a contraindication, or why the member cannot use an appropriate preferred formulary product.

    • Document trial and failure of a preferred formulary product.
    • Document a contraindication to a preferred formulary product.
    • Document inability to use an appropriate preferred product, such as when an insulin pump requires brand Humalog or Novolog.
    Denial Risk

    No Qualifying Exception to Formulary Therapy

    Deny the request as not meeting criteria when the member has not failed an appropriate preferred formulary insulin and no contraindication or documented inability to use preferred therapy is established.

    • Request a trial of an appropriate formulary alternative before using the non-preferred insulin.

    Background

    The policy promotes use of least costly insulin products as first-line therapy through the preferred formulary. A non-preferred insulin may be authorized when preferred therapy has been unsuccessful, is contraindicated, or cannot be used for a documented clinical or device-related reason, such as an insulin pump requiring brand Humalog or Novolog.

    Initial Therapy Criteria

    Initial request

    Initial requests are eligible for approval for up to 12 months when a qualifying exception to preferred formulary insulin is documented.

    Initial approval pathways

    • Preferred product failure or contraindication: The member has trialed and failed a preferred formulary product, or has a contraindication to a preferred formulary product.

      Approve for up to 12 months.

    • Preferred product cannot be used: There is documentation explaining why a preferred formulary product cannot be used.

      Some insulin pumps require brand Humalog or Novolog. Approve for up to 12 months when documented.

    Step Therapy

    StepRequirementException
    1Use an appropriate preferred formulary insulin before requesting a non-preferred insulin.The preferred product cannot be used because the member has failed therapy, has a contraindication, or documentation explains a clinical or device-related reason, such as an insulin pump requiring brand Humalog or Novolog.

    Biosimilar Coverage

    Billing Rule

    Biosimilar insulin may not require prior authorization

    Most unbranded biosimilar insulin products are on formulary without prior authorization.

    Policy Summary
    PayerAdvanced Health
    PolicyNon-Preferred Insulin Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument failure, contraindication, or inability to use a preferred formulary insulin when requesting a non-preferred insulin.
    SourceLink
    On This Page
    Coverage CriteriaProvider ActionsBackgroundInitial Therapy CriteriaStep TherapyBiosimilar Coverage