Levemir — United Healthcare
Diabetes mellitus
Preferred products
- Lantus
- Toujeo
- insulin NPH
Initial criteria
- Submission of medical records documenting history of a three month trial resulting in a therapeutic failure, contraindication, or intolerance to both Lantus and Toujeo OR member is pregnant and has a history of trial and failure, contraindication, or intolerance to insulin NPH
Reauthorization criteria
- Documentation of positive clinical response AND member is currently on medication as documented in claims history (evidence of claims in past 120 days)
Approval duration
12 months