Formulary and utilization guidance for diabetic medications and supplies
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Describes preferred insulin and non-insulin diabetes medications, substitution guidance, step therapy and prior authorization expectations, and supply limits for Kern Family Health Care providers and pharmacies.
No material clinical or coverage changes in this revision.
Coverage Criteria for Diabetes Medications and Supplies
Insulin lispro (Admelog) guidance
Coverage and preferred use guidance:
Branded products are not allowed to substitute without provider approval per FDA rules.
Insulin aspart (Novolog) guidance
Prescribe 'insulin aspart' to permit pharmacy selection of the covered formulation.
Insulin glargine (Semglee) guidance
Branded substitutability requires provider approval consistent with FDA rules.
SGLT-2 agent preference
Documentation may include clinical history, relevant labs, or medication therapy consistent with CVD.
DPP-4 agent preference
Documentation may include ejection fraction, diagnostics, or medication therapy consistent with CHF.
Adlyxin sequencing
Adlyxin is the lowest-cost GLP-1 and is a component of Soliqua; consider Adlyxin for GLP-1 prescribing when ASCVD is not present.
Soliqua coverage criteria
Soliqua is preferred when basal insulin plus GLP-1 therapy is clinically indicated.
Branded insulin products (for example, specific manufacturer labels of lispro or glargine) do not automatically substitute at the pharmacy without the prescribing provider’s approval in accordance with FDA rules. To allow the pharmacy to select the plan’s cost-preferred manufacturer, prescribers are encouraged to write orders for the generic ingredient name (for example, insulin lispro or insulin glargine) rather than a branded product. The plan designates Admelog as the preferred lispro manufacturer and Semglee as the preferred glargine manufacturer; pharmacies may dispense the formulary manufacturer when the prescription is written for the ingredient name and provider approval for substitution has been followed.
Required Provider Actions, Prior Authorization, and Documentation
Step therapy and brand substitution — provider must approve brand swaps
Branded insulin products will not be automatically substituted; provider approval is required for any brand substitution. Prescribers are encouraged to write for the generic drug name (e.g., “insulin lispro” or “insulin glargine”) so the pharmacy can dispense the formulary manufacturer.
- “The branded drugs are not allowed to substitute without an approval from the provider in accordance to FDA rules.”
- “It would be helpful for prescriptions to be written for insulin lispro and then pharmacies may select any manufacturer.”
- “Writing for insulin glargine will allow pharmacies that ability to select the covered version.”
Soliqua requires prior basal insulin or GLP-1
Coverage for Soliqua requires documented prior use of a basal insulin (Basaglar) or a GLP-1 agent before Soliqua will be approved.
- “Soliqua: Step Therapy. Requires prior use of Basaglar or GLP-1.”
- Preferred when basal insulin plus GLP-1 therapy is required.
Adlyxin sequencing — requires 90 days of SGLT-2 therapy
Adlyxin is authorized only after the patient has completed 90 days of SGLT-2 therapy; consider Adlyxin as the lower-cost GLP-1 when ASCVD is not present.
- “Adlyxin: Allowed after 90 days of SGLT-2 therapy.”
- If atherosclerotic coronary disease is absent, consider Adlyxin; if present, consider Trulicity.
Clinical justification — include labs, history, diagnostics, and medication history
Document positive clinical findings to justify non-preferred agents: labs, history of myocardial infarction, diagnostics (e.g., ejection fraction), or medication history consistent with CVD or CHF must be included in the record.
- For SGLT-2 agents: provide documentation of atherosclerotic disease (labs, history of MI, medication therapy consistent with CVD) to justify Jardiance or Farxiga.
- For DPP-4 agents: provide documentation of CHF (labs, ejection fraction, or medication profile such as diuretics, selective beta-blockers, ACE/ARB) to justify Tradjenta.
Authorization submission — use the TAR Provider portal
Submit Therapeutic Authorization Requests (TARs) through the Kern Family Health Care Provider portal; contact your organization’s system administrator for access or your Kern Provider Relations Representative if unsure.
- Portal URL: https://provider.kernfamilyhealthcare.com
- Contact your company's system administrator for user access if needed.
Denial risk — missing clinical records may deny coverage of non‑preferred agents
Absence of required clinical documentation (e.g., no records showing ASCVD or CHF when requested) may prevent coverage of non‑preferred agents such as Jardiance, Farxiga, or Tradjenta.
- “SGLT-2: Steglatro is to be used unless positive documentation of atherosclerotic disease ... is provided. In which case, the medical necessity for Jardiance or Farxiga would have been met.”
- “DPP-4: Alogliptin is to be used unless positive documentation of CHF ... is provided. In which case, the medical necessity for Tradjenta would have been met.”
- Failure to supply these records may result in denial or coverage of the preferred agent only.
Preferred Manufacturers and Step Therapy Definitions
Background and Scope
This policy clarifies preferred manufacturers and utilization expectations for insulin and select non-insulin diabetes agents used by Kern Family Health Care. Key preferences: Admelog is preferred for insulin lispro and Semglee is preferred for insulin glargine. For insulin aspart, the plan allows the authorized generic formulation.
The policy also establishes clinical selection rules for other diabetes drug classes: Steglatro is preferred among SGLT-2 agents unless there is documented atherosclerotic cardiovascular disease (in which case Jardiance or Farxiga may be medically necessary), and alogliptin is preferred among DPP-4 agents unless there is documented congestive heart failure (in which case Tradjenta may be appropriate).
Additionally, combination and sequencing requirements are specified: Soliqua requires prior use of Basaglar or a GLP-1 agent (step therapy), and Adlyxin is allowed after 90 days of SGLT-2 therapy. Documentation of clinical justification (for example, labs, history of MI, ejection fraction, or medication profile consistent with CVD/CHF) may be required to justify non-preferred agents.
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