2024 Diabetes Prescribing Aid

Date: 02/12/24

2024 Preferred Insulin Products

·         Fiasp (insulin aspart)

·         Novolog

SHORT ACTING:

·         Novolin R (NOTE: Brand RELION is NOT COVERED)

INTERMEDIATE ACTING:

·         Novolin N (NOTE: Brand RELION is NOT COVERED)

LONG ACTING:

·         Basaglar (insulin glargine)

·         Tresiba (insulin degludec)

·         Toujeo (insulin glargine)

·         Toujeo Max (insulin glargine)

COMBINATION (Insulin + GLP-1 receptor agonist):

·         Soliqua (insulin glargine + lixisenatide), Xultophy (insulin degludec + liraglutide)

C-SNP plans (Wellcare Specialty No Premium HMO C-SNP): Tier 6 [subject to Evidence of Coverage- initial coverage ($0-$10 monthly copay), and coverage gap]

D-SNP plans (Wellcare Dual Liberty HMO D-SNP): Tier 1 [subject to Evidence of Coverage]

All other plans: Tier 3 [subject to Evidence of Coverage- deductible, initial coverage (copay/cost sharing), and coverage gap]

2024 Preferred Anti-Diabetic (non-insulin) Meications

NON-DPP-4 INHIBITOR, GLP-1 AGONIST, SGLT2 INHIBITOR DRUGS:

·         Biguanide: metformin, metformin ER (generic for Glucophage XR only)

·         Thiazolidinedione: pioglitazone

·         Alpha-Glucosidase inhibitor: acarbose

·         Meglitinide analogue: nateglinide, repaglinide

·         Combinations: glipizide/metformin, pioglitazone/metformin, pioglitazone/glimepiride

All plans-$0 or low copay.

Gap coverage for Wellcare No Premium (HMO) and Wellcare No Premium Open (PPO) plans.

DPP-4 INHIBITOR:

·         Januvia, Tradjenta

DPP-4 COMBINATION:

·         Glyxambi, Janumet, Janumet XR, Jentodueto, Jentodueto XR, Trijardy

C-SNP plans: (Wellcare Specialty No Premium HMO C-SNP): $0 or low copay EXCEPT Glyxambi and Trijardy which are Tier 3.  No gap coverage

D-SNP plans (Wellcare Dual Liberty (HMO D-SNP): all $0 or low copay.

Non-C-SNP and Non-D-SNP plans: Tier 3.  No gap coverage.

SGLT-2 INHIBITOR:

·         Farxiga, Jardiance, Invokana*

SGLT-2 INHIBITOR COMBINATION:

·         Glyxambi, Synjardy, Synjardy XR, Trijardy, Xigduo, Invokamet*, Invokamet XR*

*Invokana, Invokamet, and Invokamet XR: NOT PREFERRED for D-SNP plans and Tier 4 for all other plans

Farxiga and Jardiance- $0 for D-SNP plans and Tier 3 for all other plans

GLP-1 AGONIST: Bydureon, Ozempic, Mounjaro, Rybelsus, Trulicity

D-SNP plans: $0 or low copay

Non- D-SNP plans: Tier 3

All plans: require prior authorization

2024 Preferred Blood Glucose Meters and Strips

·         One Touch Verio Reflect or Verio Flex meter & One Touch Verio test strips

·         One Touch Ultra 2 meter & One Touch Ultra test strips

Test Strip Quantity Limits:

·         Non-insulin users: 100 strips/90 days           

·         Insulin users: 100 strips/30 days

Continuous Glucose Monitoring (CGM) systems require Prior Authorization (PA).

·         FreeStyle Libre or DexCom are preferred/PA required

·         PA criteria: DM diagnosis, insulin-treated, has had more than one level 2 hypoglycemic event (BG < 54 mg/dL) that persists despite more than one attempt to adjust medications and/or modify diabetes treatment plan OR one level 3 hypoglycemic event (BG <54 mg/dL) characterized by altered mental and/or physical state requiring third-party assistance for treatment, seen by provider in last 6 months & will have follow-up appointments every 6 months to document adherence to both the CGM regimen and diabetes treatment plan

·         The Coverage Determination form for PA request is available on our website at www.Wellcare.com/allwellAZ