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PAxx Lantus insulin/ gargline

U.S. Doctors Resources, L.L.C.



Lantus® (insulin glargine)


Insulin Requiring Diabetes Mellitus


The Prior Authorization for this medication has been denied. Further review is pending as:

Novolin is Free of Deductible.

1. There is no superiority of commercial preparations of any insulin for Insulin Requiring Diabetes Mellitus[1], therefore, Novulin, Novulin NPH and Novulin 70/30 are approved by the Benefit Manager. Record symptoms initially and at 3-months in non-critical patients.

2. Contact Benefit Manager for Referral for an Alternative Pricing. In addition to insulin, only Metformin[2] is approved for appropriate diabetic patients.

3. Contact Benefit Manager for potential Referral for the Protocol for Anabolic Therapy for Diabetes as indicated.[3]

Pending (1.), (2.) and (3.), the employee/ dependent may continue the medication as prescribed by the treating physician by attaching a valid 3-month prescription with up to 12-months of refills to the Cover Page and mailing it back to:

ATTN: Benefit Manager
City of Hazel Park Self-Insurance Health Program
111 East Nine Mile Road
Hazel Park, Michigan 48030

Please send the demographics about the patient that appear on the Cover Page of the Prior Authorization form and the Credit Card Information from the Flexible Spending Account in the boxes below.


Demographics Health Insurance/ Credit Card
Member Name:____________________________________ Member Name on the Card:_____________________________________
Insurance ID:____________________________________ Issuing Service: VISA, MC, Discover _________________
Date of Birth:____________________________________ Number:____________________________________
Street Address:____________________________________ Expiration:____________________________________
City/ State/ Zip code:____________________________________CVV Code:____________________________________
Telephone Number:____________________________________
Signature of Employee/ Insured:

Signature of Treating Physician:___________________________________

1. Costs Associated With Using Different Insulin Preparations Tracy Tylee, MD1; Irl B. Hirsch, MD1 [+] Author Affiliations JAMA. 2015;314(7):665-666. doi:10.1001/jama.2015.7032.

3. J Endocrinol. 2006 Jun;154(6):899-906. Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes. Kapoor D1, Goodwin E, Channer KS, Jones TH

Signed b.n.r. Benefit Manager ___________________________________ date:__________

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