Effective immediately, Harvard Pilgrim is now covering the medication Afrezza with prior authorization on the Premium formularies. Afrezza is a new rapid-acting inhaled insulin used to improve glycemic control in adults with diabetes mellitus.
Afrezza will be covered on the Premium formularies only, at the highest tier (i.e. Tier 3 on the 3-Tier and Tier 4 on the 4-Tier). Harvard Pilgrim is requiring prior authorization to ensure the safe and appropriate use of Afrezza. Harvard Pilgrim’s Afrezza Clinical Coverage Criteria detail the requirements that must be met in order to obtain prior authorization, including:
- Patient is 18 years of age or older
- There has been a previous trial of a rapid-acting injectable insulin (e.g. Novolog, Humalog, Apidra) or the patient is unable or unwilling to administer injectable insulin.
- For patients with Type 1 Diabetes: concomitant use with a long-acting insulin (e.g. Lantus, Levemir).
- For patients with Type 2 Diabetes: inadequate control on, intolerance to, or contraindication to at least 2 oral anti-diabetic medications.
- Patient does not have a diagnosis of lung disease (such as asthma or COPD).
- Patient does not currently smoke tobacco products and has not used them within the past 6 months.
Approvals will be for 12 months. Harvard Pilgrim will require the following in order to obtain a renewal of the prior authorization: assessment of pulmonary function within the past year showing no more than a 20% decline in pulmonary function from baseline, and confirmation that the patient is not currently smoking tobacco products or has not used them within the past 6 months.
To request prior authorization, please complete the Afrezza Medication Request Form and fax it to MedImpact HealthCare Systems at 888-807-6643. For more information, please refer to the Pharmacy section of Harvard Pilgrim’s provider website.