Diabetes, Insulins
PDL Reference Documents
Newsletters
- May 2020 - Optimizing the Use of NPH Insulin in Patients with Type 2 Diabetes Mellitus
- December 2018 - Basal Insulin Update
- November 2017 - Marketing Claims of Newer Drugs and the Evidence
- March 2016 - Antidiabetic Treatments and Cardiovascular Implications
- October 2013 - Updates and Comparisons of Type 2 Diabetes Treatment Guidelines
- June 2012 - Can The Diabetic War Be Fought By Aggressive Blood Pressure Control?
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
---|---|---|---|---|---|
insulin aspart | NOVOLOG PENFILL | CARTRIDGE | Y | ||
insulin aspart | INSULIN ASPART PENFILL | CARTRIDGE | Y | ||
insulin aspart | NOVOLOG FLEXPEN | INSULN PEN | Y | ||
insulin aspart | INSULIN ASPART FLEXPEN | INSULN PEN | Y | ||
insulin aspart | INSULIN ASPART | VIAL | Y | ||
insulin aspart | NOVOLOG | VIAL | Y | ||
insulin aspart prot/insuln asp | NOVOLOG MIX 70-30 FLEXPEN | INSULN PEN | Y | PA Document | |
insulin aspart prot/insuln asp | INSULIN ASPART PROT MIX 70-30 | INSULN PEN | Y | PA Document | |
insulin aspart prot/insuln asp | NOVOLOG MIX 70-30 | VIAL | Y | PA Document | |
insulin aspart prot/insuln asp | INSULIN ASPART PROT MIX 70-30 | VIAL | Y | PA Document | |
insulin detemir | LEVEMIR FLEXTOUCH | INSULN PEN | Y | ||
insulin detemir | LEVEMIR FLEXPEN | INSULN PEN | Y | ||
insulin detemir | LEVEMIR | VIAL | Y | ||
insulin glargine,hum.rec.anlog | LANTUS SOLOSTAR | INSULN PEN | Y | ||
insulin glargine,hum.rec.anlog | LANTUS | VIAL | Y | ||
insulin glulisine | APIDRA SOLOSTAR | INSULN PEN | Y | ||
insulin glulisine | APIDRA | VIAL | Y | ||
insulin lispro | HUMALOG | CARTRIDGE | Y | ||
insulin lispro | INSULIN LISPRO JUNIOR KWIKPEN | INS PEN HF | Y | ||
insulin lispro | HUMALOG JUNIOR KWIKPEN | INS PEN HF | Y | ||
insulin lispro | INSULIN LISPRO KWIKPEN U-100 | INSULN PEN | Y | ||
insulin lispro | HUMALOG TEMPO PEN U-100 | INSULN PEN | Y | ||
insulin lispro | HUMALOG KWIKPEN U-200 | INSULN PEN | Y | ||
insulin lispro | HUMALOG KWIKPEN U-100 | INSULN PEN | Y | ||
insulin lispro | INSULIN LISPRO | VIAL | Y | ||
insulin lispro | HUMALOG | VIAL | Y | ||
insulin lispro protamin/lispro | HUMALOG MIX 75-25 KWIKPEN | INSULN PEN | Y | ||
insulin lispro protamin/lispro | HUMALOG MIX 50-50 KWIKPEN | INSULN PEN | Y | ||
insulin lispro protamin/lispro | INSULIN LISPRO PROTAMINE MIX | INSULN PEN | Y | ||
insulin lispro protamin/lispro | HUMALOG MIX 75-25 | VIAL | Y | ||
insulin NPH hum/reg insulin hm | NOVOLIN 70-30 FLEXPEN | INSULN PEN | Y | PA Document | |
insulin NPH hum/reg insulin hm | HUMULIN 70/30 KWIKPEN | INSULN PEN | Y | PA Document | |
insulin NPH hum/reg insulin hm | NOVOLIN 70-30 INNOLET | INSULN PEN | Y | PA Document | |
insulin NPH hum/reg insulin hm | NOVOLIN 70-30 | VIAL | Y | PA Document | |
insulin NPH hum/reg insulin hm | HUMULIN 70-30 | VIAL | Y | PA Document | |
insulin NPH hum/reg insulin hm | HUMULIN 70/30 | VIAL | Y | PA Document | |
insulin NPH hum/reg insulin hm | NOVOLIN 70-30 | VIAL | Y | PA Document | |
insulin NPH human isophane | NOVOLIN N | VIAL | Y | ||
insulin NPH human isophane | HUMULIN N | VIAL | Y | ||
insulin NPH human isophane | NOVOLIN N | VIAL | Y | ||
insulin regular, human | HUMULIN R U-500 KWIKPEN | INSULN PEN | Y | ||
insulin regular, human | NOVOLIN R | VIAL | Y | ||
insulin regular, human | HUMULIN R U-500 | VIAL | Y | ||
insulin regular, human | HUMULIN R | VIAL | Y | ||
insulin regular, human | NOVOLIN R | VIAL | Y | ||
insulin regular, human | HUMULIN R | VIAL | Y | ||
insulin zinc human recombinant | NOVOLIN L | VIAL | Y | ||
insulin aspart (niacinamide) | FIASP PENFILL | CARTRIDGE | N | PA Document | |
insulin aspart (niacinamide) | FIASP FLEXTOUCH | INSULN PEN | N | PA Document | |
insulin aspart (niacinamide) | FIASP | VIAL | N | PA Document | |
insulin aspart/B3/pump cart | FIASP PUMPCART | CARTRIDGE | N | PA Document | |
insulin degludec | INSULIN DEGLUDEC PEN (U-200) | INSULN PEN | N | PA Document | |
insulin degludec | INSULIN DEGLUDEC PEN (U-100) | INSULN PEN | N | PA Document | |
insulin degludec | TRESIBA FLEXTOUCH U-100 | INSULN PEN | N | PA Document | Mar 31, 2016 |
insulin degludec | TRESIBA FLEXTOUCH U-200 | INSULN PEN | N | PA Document | Mar 31, 2016 |
insulin degludec | TRESIBA | VIAL | N | PA Document | |
insulin degludec | INSULIN DEGLUDEC | VIAL | N | PA Document | |
insulin degludec/liraglutide | XULTOPHY 100-3.6 | INSULN PEN | N | PA Document | |
insulin glargine-aglr | REZVOGLAR KWIKPEN | INSULN PEN | N | PA Document | |
insulin glargine-yfgn | SEMGLEE (YFGN) PEN | INSULN PEN | N | PA Document | |
insulin glargine-yfgn | INSULIN GLARGINE-YFGN | INSULN PEN | N | PA Document | |
insulin glargine-yfgn | SEMGLEE (YFGN) | VIAL | N | PA Document | |
insulin glargine-yfgn | INSULIN GLARGINE-YFGN | VIAL | N | PA Document | |
insulin glargine,hum.rec.anlog | TOUJEO MAX SOLOSTAR | INSULN PEN | N | PA Document | |
insulin glargine,hum.rec.anlog | TOUJEO SOLOSTAR | INSULN PEN | N | PA Document | |
insulin glargine,hum.rec.anlog | INSULIN GLARGINE SOLOSTAR | INSULN PEN | N | PA Document | |
insulin glargine,hum.rec.anlog | BASAGLAR KWIKPEN U-100 | INSULN PEN | N | PA Document | |
insulin glargine,hum.rec.anlog | BASAGLAR TEMPO PEN U-100 | INSULN PEN | N | PA Document | |
insulin glargine,hum.rec.anlog | INSULIN GLARGINE MAX SOLOSTAR | INSULN PEN | N | PA Document | |
insulin glargine,hum.rec.anlog | INSULIN GLARGINE | VIAL | N | PA Document | |
insulin glargine/lixisenatide | SOLIQUA 100-33 | INSULN PEN | N | PA Document | |
insulin lispro | ADMELOG SOLOSTAR | INSULN PEN | N | PA Document | |
insulin lispro | ADMELOG | VIAL | N | PA Document | |
insulin lispro-aabc | LYUMJEV TEMPO PEN U-100 | INSULN PEN | N | PA Document | |
insulin lispro-aabc | LYUMJEV KWIKPEN U-200 | INSULN PEN | N | PA Document | |
insulin lispro-aabc | LYUMJEV KWIKPEN U-100 | INSULN PEN | N | PA Document | |
insulin lispro-aabc | LYUMJEV | VIAL | N | PA Document | |
insulin NPH human isophane | HUMULIN N KWIKPEN | INSULN PEN | N | PA Document | |
insulin NPH human isophane | NOVOLIN N FLEXPEN | INSULN PEN | N | PA Document | |
insulin regular, human | AFREZZA | CART INHAL | N | PA Document | Sep 23, 2014 |
insulin regular, human | NOVOLIN R FLEXPEN | INSULN PEN | N | PA Document | |
insulin regular in 0.9 % NaCl | MYXREDLIN | PLAST. BAG |