CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Humulin R

Defines prior authorization criteria, quantity limits, and coverage duration for Humulin R for Medicaid members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHumulin R

Policy CodePolicy N/A

Change TypeNo material change reported

Effective DateJul 1, 2018

Next Review Date

Key ActionPrior authorization may be granted only when the member has a diagnosis of diabetes mellitus and requires more than 200 units of insulin per day.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical criteria or coverage were reported.

2Approval Criteria

12 monthsCoverage Duration

Vial & Pen limitsQuantity-Limit Types

Coverage Summary

Neighborhood Health Plan of Rhode Island covers Humulin R (regular human insulin) with prior authorization for Medicaid members when the drug is prescribed for a diagnosis of diabetes mellitus and the patient’s daily insulin requirement is > 200 units/day. Coverage is provided for 12 months. Quantity limits are vials: 0.67 ml/day (20 ml per 30 days) and pens: 0.8 ml/day (24 ml per 30 days).

Initial Therapy Criteria

Criteria for Approval

An authorization may be granted when all the following criteria are met:

ALL of the following

Diagnosis: The requested drug is being prescribed for a diagnosis of diabetes mellitus
Daily insulin requirement: The patient requires more than 200 units of insulin per day> 200 units/day

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required

Prior authorization may be granted only when the member has a diagnosis of diabetes mellitus and requires more than 200 units of insulin per day.

Documentation Required

Documentation required

Provider must document diagnosis of diabetes mellitus and evidence supporting requirement of >200 units of insulin per day to support authorization.

Billing Rule

Quantity limits

Limit vials to 0.67 ml/day (20 ml per 30 days) and pens to 0.8 ml/day (24 ml per 30 days).

Vial limit: 0.67 ml/day (20 ml per 30 days)
Pen limit: 0.8 ml/day (24 ml per 30 days)

Background & Definitions

This policy governs Medicaid coverage of Humulin R for members who require high-dose insulin therapy. Authorization is contingent on a documented diagnosis of diabetes mellitus and a daily insulin requirement of > 200 units/day. When authorized, coverage duration is 12 months. Quantity limits are set at vials: 0.67 ml/day (20 ml per 30 days) and pens: 0.8 ml/day (24 ml per 30 days). Payer: Neighborhood Health Plan of Rhode Island.

Humulin R: Regular human insulin (document subject).