Lyumjev Tempo Pen — Medical Mutual

Preferred products

• Humalog (insulin lispro injection – Lilly [U-100 and U-200], authorized generic for U-100)
• Humalog 50/50 mix (50% insulin lispro protamine suspension/50% insulin lispro injection – Lilly)
• Humalog Mix 75/25 (75% insulin lispro protamine suspension/25% insulin lispro injection – Lilly, authorized generic)
• Humalog Tempo Pen (insulin lispro injection – Lilly)
• Lyumjev (vials and KwikPen) (insulin lispro-aabc injection – Eli Lilly)

Initial criteria

• Patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents OR
• Patient has a contraindication to all preferred agents OR
• Patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
• - Patient has at least 130 days of prescription claims history on file supporting receipt of the requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested non-preferred product OR
• - Prescriber verifies that the patient has been receiving the requested non-preferred agent for 90 days via paid claims AND there is no generic equivalent available for the requested non-preferred product

Reauthorization criteria

• Continuation of therapy with documented stability

Approval duration

1 year