Formulary and prior authorization guidance for diabetic medications
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This document communicates formulary preferences, step therapy and prior authorization requirements for various diabetes medications and related supplies for Kern Family Health Care members; it is addressed to providers and pharmacies.
As of October 1, 2019, only Admelog will be authorized among insulin lispro brands.
As of October 1, 2019, only Steglatro/Segluromet and Jardiance/Synjardy will be authorized among SGLT-2 options.
Coverage Criteria & Formulary Preferences
Coverage conditions and preferred products
Coverage and authorization decisions are governed by manufacturer preference, step therapy, and prior authorization as follows.
Provider approval required to substitute branded products per FDA rules.
Adlyxin identified as lowest cost GLP-1 and component of Soliqua.
Step therapy requirement — prior use required.
Preference based on indication and formulary authorization as of 10/1/2019.
Class preference driven by generic availability and heart-failure risk considerations.
Device coverage determined by documented history of device use.
Kern Family Health Care considers the available branded insulin lispro products clinically equivalent. Coverage and authorization are governed by manufacturer preference and documentation of provider approval for any branded substitution. As stated by the plan, Admelog is the preferred/authorized insulin lispro product and, effective October 1, 2019, it is the only insulin lispro that will be authorized. To facilitate pharmacy-level dispensing of the preferred manufacturer, prescriptions should be written generically for "insulin lispro" so pharmacies can select the formulary manufacturer.
Branded-to-branded substitution of insulin lispro without documented provider approval is not permitted per FDA rules and the plan will not authorize non-preferred manufacturers. Specifically, the plan notes that the two branded lispro products may not be substituted without provider approval and that, as of 10/01/2019, non-preferred brands (for example, Humalog) will not be authorized unless provider approval is documented.
Coding and Timing Rules
| No codes listed |
Provider Actions, Prior Authorization & Documentation
Prior authorization and step therapy requirements
Certain diabetes products are subject to prior authorization and step therapy: Soliqua requires prior use of Basaglar or a GLP‑1 before coverage; Adlyxin is only allowed after 90 days of SGLT‑2 therapy. As of October 1, 2019, only Admelog is authorized among insulin lispro brands; SGLT‑2 coverage is limited to Steglatro/Segluromet and Jardiance/Synjardy. Submit TARs via the provider portal for authorization requests.
- Soliqua: requires prior use of Basaglar or a GLP‑1 (step therapy).
- Adlyxin: allowed only after 90 days of SGLT‑2 therapy.
- Insulin lispro: only Admelog authorized as of 10/1/2019.
- SGLT‑2 agents: only Steglatro/Segluromet and Jardiance/Synjardy authorized as of 10/1/2019.
Step therapy rules — Soliqua and Adlyxin
Follow the specified step requirements when requesting coverage: Soliqua requires documentation of prior use of Basaglar or another GLP‑1; Adlyxin is covered only after the member has completed 90 days of SGLT‑2 therapy.
- Document prior Basaglar or GLP‑1 usage before Soliqua is authorized.
- Document 90 days of SGLT‑2 therapy before Adlyxin will be allowed.
Submission and provider approval (TAR process)
Submit Treatment Authorization Requests (TARs) through the Kern provider portal and document provider approval when requesting branded substitutions or non‑preferred manufacturers; contact your organization’s system administrator for portal access if needed.
- Submit TARs via https://provider.kernfamilyhealthcare.com.
- Document provider approval when requesting branded substitution (per FDA rules).
- Contact your company system administrator or Kern Provider Relations for portal access questions.
Denial risk for non‑preferred manufacturer requests
Requests for non‑preferred manufacturers or branded substitutions may be denied unless the provider documents approval; after October 1, 2019 only the preferred manufacturers listed will be authorized.
- Branded insulin lispro substitutions are not allowed without provider approval per FDA rules; only Admelog will be authorized as of 10/1/2019.
- Non‑preferred SGLT‑2 products will not be authorized after 10/1/2019 except Steglatro/Segluromet and Jardiance/Synjardy.
Definitions and Procedural Terms
Background and Rationale
Background rationale: multiple manufacturers produce insulin lispro but the products are clinically the same, so formulary choice is driven by cost and manufacturer selection. The policy reflects this by designating the most cost‑effective manufacturer as formulary and by preferring Admelog as the authorized lispro product starting October 1, 2019. Writing prescriptions generically for insulin lispro allows pharmacies to dispense the formulary (preferred) manufacturer and supports cost‑effective care.
New Starts & Initiation Guidance
New starts guidance
Preferences for new therapy starts or after therapy breaks.
As of October 1, 2019, only Steglatro/Segluromet and Jardiance/Synjardy will be authorized.
Select alogliptin when clinically appropriate; avoid in HF risk.
Step Therapy Table
| Medication | Step therapy requirement | Notes / threshold |
|---|---|---|
| Adlyxin (lixisenatide) | ||
| Allowed only after 90 days of SGLT-2 therapy | ||
| Identified as lowest-cost GLP-1 and is a component of Soliqua; 90-day SGLT-2 duration required before coverage |
| Medication | Step therapy requirement | Notes |
|---|---|---|
| Soliqua (insulin glargine/lixisenatide combination) | ||
| Requires prior use of Basaglar or a GLP-1 | ||
| Preferred when a member requires both basal insulin and GLP-1 therapy; step therapy prerequisite must be met before coverage |
Device & Site of Care Coverage Guidance
Document prior device use to determine home supplies
Coverage of pen needles versus syringes for home use is determined by documented history of device use: allow pen needles when prior insulin pen use is documented and syringes when prior vial use is documented.
- Pen needles: allowed if patient history shows prior use of insulin pens.
- Syringes: allowed if patient history shows prior use of insulin vials.
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