Lyumjev — Blue Cross Blue Shield of Oklahoma

Preferred products

• Admelog
• Apidra
• Humalog
• Humalog U200
• Merilog
• NovoLog
• Humulin R U-100
• Novolin R
• ReliOn R
• Humulin N
• Novolin N
• Humalog 75/25
• Humalog 50/50
• Humulin 70/30

Initial criteria

• 1. The patient is currently being treated with the requested agent and is currently stable on the requested agent OR
• 2. BOTH of the following: (A) The requested agent is a rapid insulin AND (B) ONE of the following: (1) The patient is using an insulin pump that has an incompatibility with ALL preferred rapid insulin agents not expected to occur with the requested agent OR (2) The patient has tried and had an inadequate response to ALL preferred rapid acting insulin agents not expected to occur with the requested agent OR (3) ALL preferred rapid acting insulin agents were discontinued due to lack of efficacy, diminished effect, or adverse event OR (4) The patient has an intolerance or hypersensitivity to ALL preferred rapid acting insulin agents not expected to occur with the requested agent OR (5) The patient has an FDA labeled contraindication to ALL preferred rapid acting insulin agents not expected to occur with the requested agent OR (6) ALL preferred rapid acting insulin agents are expected to be ineffective or cause adverse reaction, barrier to adherence, worsen comorbidity, or decrease functional ability OR (7) ALL preferred rapid acting insulin agents are not in the best interest of the patient based on medical necessity OR (8) The patient has tried another prescription drug in the same pharmacologic class or mechanism and discontinued due to lack of efficacy or adverse event)
• 3. BOTH of the following: (A) The requested agent is a regular insulin AND (B) ONE of the following: (1) The patient has tried and had inadequate response to ALL preferred regular insulin agents not expected to occur with the requested agent OR (2) ALL preferred regular insulin agents discontinued due to lack of efficacy, diminished effect, or adverse event OR (3) Intolerance or hypersensitivity to ALL preferred regular insulin agents not expected to occur with the requested agent OR (4) FDA labeled contraindication to ALL preferred regular insulin agents not expected to occur with the requested agent OR (5) ALL preferred regular insulin agents ineffective or cause barriers to adherence or adverse effects OR (6) ALL preferred regular insulin agents not in best interest of patient OR (7) Tried another prescription drug in same class and discontinued due to lack of efficacy or adverse event)
• 4. BOTH of the following: (A) The requested agent is a mixed insulin AND (B) ONE of the following: (1) The patient has tried and had inadequate response to ALL preferred mixed insulin agents not expected to occur with the requested agent OR (2) ALL preferred mixed insulin agents discontinued due to lack of efficacy, diminished effect, or adverse event OR (3) Intolerance or hypersensitivity to ALL preferred mixed insulin agents not expected to occur with the requested agent OR (4) FDA labeled contraindication to ALL preferred mixed insulin agents not expected to occur with the requested agent OR (5) ALL preferred mixed insulin agents ineffective or cause barriers to adherence or adverse effects OR (6) ALL preferred mixed insulin agents not in best interest of patient OR (7) Tried another prescription drug in same class and discontinued due to lack of efficacy or adverse event)
• 5. The requested agent is medically necessary and appropriate for the patient OR
• 6. The patient has a physical or mental disability that would prevent use of ALL preferred insulin agents OR
• 7. The patient is pregnant
• The requested agent will also be approved when: (1) Member resides in Ohio AND (2) Plan is Fully Insured or HIM Shop (SG) AND BOTH (A) No FDA labeled contraindications to the requested agent AND (B) ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication supported in compendia for the requested agent and route of administration)

Approval duration

12 months