CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid_Insulinglargine300_062525

Policy governs prior authorization criteria, quantity limit, and coverage duration for Insulin Glargine 300 units/ml for Medicaid members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Insulinglargine300_062525

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review Date

Key ActionAuthorization may be granted only if all approval criteria are met: patient age ≥ 6 years, diagnosis of diabetes mellitus, and patient requires ≥ 100 units of insulin per day.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

≥100Minimum daily units required

1 ml/dayQuantity limit

12 monthsCoverage duration

≥6Minimum covered age

Coverage Summary

Coverage stance: covered_with_criteria for Insulin Glargine 300 units/ml (Toujeo) under the Medicaid plan of Neighborhood Health Plan of Rhode Island. Scope: this policy governs prior authorization criteria, quantity limit, and coverage duration for Insulin Glargine 300 units/ml for Medicaid members. Prior authorization criteria require that all approval conditions are met (patient age ≥ 6 years; diagnosis of diabetes mellitus; patient requires ≥ 100 units of insulin per day). Quantity limit: 1 ml/day. Coverage duration when authorized: 12 months. Effective date: 7/1/2025. Last review: 6/25/2025.

Initial Therapy Criteria

Criteria for Approval

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

ALL of the following

Age: The patient is 6 years of age or older
Diagnosis: The requested drug is being prescribed for a diagnosis of diabetes mellitus
Daily insulin requirement: The patient requires ≥ 100 units of insulin per day>= 100 units/day

Continuation Therapy Criteria

Continuation/renewal expectations: Authorization duration when approved is 12 months. Renewals should follow the same prior authorization requirements (patient age ≥ 6 years, diagnosis of diabetes mellitus, and requirement for ≥ 100 units of insulin per day) as outlined in the approval criteria.

Provider Actions & Billing Rules

Prior Authorization

Prior authorization requirement

Authorization may be granted only if all approval criteria are met: patient age ≥ 6 years, diagnosis of diabetes mellitus, and patient requires ≥ 100 units of insulin per day.

Billing Rule

Quantity limit

Quantity limited to 1 ml per day.

Documentation Required

Documentation of insulin requirement

Provider must document diagnosis of diabetes mellitus, patient age, and evidence that patient requires ≥ 100 units of insulin per day.

Background

Background: Insulin Glargine 300 units/ml is a long-acting basal insulin formulation. This policy specifies authorization criteria for Insulin Glargine 300 units/ml (Toujeo), including minimum covered age (Age ≥ 6 years), required diagnosis (diabetes mellitus), and a high-dosage threshold of ≥ 100 units per day for consideration of approval.

Clinical Evidence

Evidence: No specific clinical trials or guideline citations are provided in the brief. Please populate this section with any relevant clinical trial data or guideline references (including study names, key outcomes, and guideline recommendations) if available; otherwise omit trial metrics.