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PAxx Novolog/ insulin/ PAxx Novulin/ PAxx Humulin


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

PRIOR AUTHORIZATION


DRUG THERAPY:

Novolog® insulin


Novulin® insulin
Humalog® insulin
Humalin® insulin

Disease

Insulin Requiring Diabetes Mellitus


MEDICAL REVIEW and DECISION:

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

Novolin® insulins are Free of Deductible.


1. There is no superiority of commercial preparations of any insulin for Insulin Requiring Diabetes Mellitus[1], therefore, Novolin®, Novolin® NPH and Novolin® 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, Metformin[2] is approved for appropriate diabetic patients.

3. Contact Benefit Manager for potential Referral for Anabolic Therapy Protocol 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.






IDENTIFICATION:



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:___________________________________





References:
1. http://jama.jamanetwork.com/article.aspx?articleid=2428963: Costs Associated With Using Different Insulin PreparationsTracy Tylee, MD1; Irl B. Hirsch, MD. JAMA. 2015;314(7):665-666. doi:10.1001/jama.2015.7032

2. http://www.ncbi.nlm.nih.gov/pubmed/25151573: Clin Ther. 2014 Nov 1;36(11):1576-87. doi: 10.1016/j.clinthera.2014.07.019. Epub 2014 Aug 20. Cost-effectiveness of insulin glargine versus sitagliptin in insulin-naïve patients with type 2 diabetes mellitus. Brown ST1, Grima DG2, Sauriol L3.

3. http://www.ncbi.nlm.nih.gov/pubmed/16728551: Eur 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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