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Afrezza (insulin regular human) — Blue Cross Blue Shield of Texas

diabetes mellitus type 2

Preferred products

  • Fiasp (insulin aspart)
  • Humalog (insulin lispro)
  • Humalog U200 (insulin lispro)
  • Lyumjev (insulin lispro-aabc)
  • NovoLog (insulin aspart)

Initial criteria

  • 1. ONE of the following: A. Patient has a diagnosis of diabetes mellitus type 1 AND is currently on long acting insulin therapy OR B. Patient has a diagnosis of diabetes mellitus type 2
  • 2. Patient has received ALL of the following to identify any potential lung disease: A. Detailed medical history review AND B. Physical examination AND C. Spirometry with Forced Expiratory Volume in 1 second (FEV1)
  • 3. Patient has not smoked in the past 6 months
  • 4. If the patient has an FDA labeled indication, then ONE of the following: A. Age is within FDA labeling for the requested indication and agent OR B. There is support for using the requested agent for the patient's age for the requested indication
  • 5. ONE of the following: A. Request is for BCBS IL Fully Insured, ASO Cost/BBF, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR B. Prescriber states the patient is currently being treated with and stable on the requested agent OR C. Patient has tried and had inadequate response to ONE preferred agent OR D. ONE preferred agent was discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event OR E. Patient has intolerance or hypersensitivity to ONE preferred agent (not expected with requested agent) OR F. Patient has FDA labeled contraindication to ALL preferred agents (not expected with requested agent) OR G. ONE preferred agent expected to be ineffective or cause significant barrier, worsen comorbidity, decrease functional ability, or cause harm OR H. ONE preferred agent not in best interest of patient based on medical necessity OR I. Patient has tried another drug in same class as ONE preferred agent and discontinued due to inadequate efficacy/effectiveness/adverse event OR J. Requested agent medically necessary and appropriate OR K. Support that patient has physical or mental disability preventing use of preferred rapid acting insulin agent OR L. Patient has documented needle phobia
  • 6. Patient does NOT have any FDA labeled contraindications to requested agent
  • Alternate pathway: Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND ALL of the following—patient does NOT have FDA labeled contraindications AND ONE of: 1. Another FDA labeled indication OR 2. Indication supported in compendia OR 3. Prescriber submitted two peer-reviewed journal articles supporting proposed use (acceptable designs randomized, double-blind, placebo-controlled; not case reports)

Reauthorization criteria

  • 1. Patient previously approved for requested agent through plan's prior authorization process
  • 2. Patient has had clinical benefit with requested agent
  • 3. Patient has received ALL of the following to identify potential lung disease: A. Detailed medical history review AND B. Physical examination AND C. Spirometry with FEV1
  • 4. Patient has not smoked in past 6 months
  • 5. Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months