Outpatient diabetes medication formulary, step therapy, prior authorization, and supply limits
Customize your policy alerts
Sign up for all kernfamilyhealthcare policy alerts
Know when kernfamilyhealthcare releases new policies or updates existing guidance.
Monitor payer policy activity
This document describes Kern Family Health Care's preferred manufacturers, step therapy and prior authorization expectations, and supply limits for outpatient diabetes medications and related supplies for providers and pharmacies.
No material clinical or coverage changes in this revision.
Coverage Criteria for Outpatient Diabetes Medications
Insulin lispro
Coverage and preference guidance applies as follows:
Prescriptions should be written generically for 'insulin lispro' to allow pharmacy selection.
SGLT-2 agents
Documentation of ASCVD required to justify Jardiance.
DPP-4 agents
Documentation of CHF required to justify Tradjenta.
GLP-1 and combination products
Soliqua identified as preferred for combined basal insulin + GLP-1 use.
Injection supplies
Kern Family Health Care follows FDA guidance and plan rules regarding substitution of branded and generic insulin products. There is no automatic traditional brand/generic substitution for certain insulins (for example, Novolog authorized generic insulin aspart) because of how the FDA views insulin interchangeability; substitutions between two branded insulin lispro products (Admelog and Humalog) also require provider approval before a pharmacy may change the manufacturer. Prescriptions should be written generically as "insulin lispro" to allow the pharmacy to dispense the plan-preferred manufacturer when appropriate.
Initial Agent Selection and Requirements
Initial agent selection
Step Therapy Requirements
| Medication | Step therapy requirement | Duration / Notes |
|---|---|---|
| Adlyxin | Allowed only after 90 days of SGLT-2 therapy | 90 days — lowest-cost GLP-1; component of Soliqua |
| Medication | Step therapy requirement | Duration / Notes |
|---|---|---|
| Soliqua | Requires prior use of Basaglar or a GLP-1 before coverage | Preferred for patients needing both basal insulin and GLP-1 therapy |
Provider Actions and Authorization Requirements
Submit TARs via Provider portal
Certain branded or non-preferred diabetes medications require prior authorization or step therapy; submit TARs for these medications through the Kern provider portal for approval.
- Submit TARs via https://provider.kernfamilyhealthcare.com
- Contact your company's system administrator for portal access or your Kern Provider Relations Representative if unsure
Soliqua & Adlyxin step-therapy rules
Follow step-therapy requirements: Adlyxin is allowed only after 90 days of SGLT-2 therapy; Soliqua requires prior use of Basaglar or a GLP-1 before coverage.
- Adlyxin: coverage allowed after 90 days of SGLT-2 therapy
- Soliqua: requires prior use of Basaglar or a GLP-1 (step therapy)
Provide clinical documentation for exceptions
When requesting coverage for non-preferred agents (e.g., Jardiance for ASCVD or Tradjenta for CHF), provide positive clinical documentation that demonstrates medical necessity.
- For Jardiance: documentation of atherosclerotic cardiovascular disease (labs, history of MI, or medication therapy consistent with CVD)
- For Tradjenta: documentation of congestive heart failure (e.g., ejection fraction, relevant labs/diagnostics, or medication history supportive of CHF)
Use portal or expect delays
Failure to submit TARs via the Provider portal may delay authorization processing; use the portal to avoid delays and contact your system administrator for access.
- Portal URL: https://provider.kernfamilyhealthcare.com
- If you lack access, contact your company's system administrator or Kern Provider Relations
Quantity Limits and Supply Restrictions
Definitions
Background and Clinical Rationale
Insulin lispro products (Admelog and Humalog) are clinically equivalent rapid‑acting insulins. Kern Family Health Care designates Admelog as the preferred manufacturer and places the most cost‑effective manufacturer on the formulary. To support formulary selection, providers are asked to prescribe using the generic name insulin lispro so pharmacies can select the preferred manufacturer.
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.