Diagnosis: Diabetes.
Treatment: Humalog.
The insurer denied Humalog.
The health plan's determination is overturned.

This is a female diagnosed with T1DM (type I diabetes mellitus). As per the provider; the patient must be able to bolus insulin in half unit increments. She is on Lantus 24-25 units daily; Novolog with ICR (Insulin to Carb Ratio) was 1:10; ISF (Insulin sensitivity factor) was 1:40 target of 120. The plan formulary drugs are Fiasp and Novalog. The provider is requesting Humalog Jr (insulin lispro).

The formulary drug would not be as effective as the non-formulary drug as the formulary drug is not available in half unit increments. The physician reports that the patient must bolus in half unit increments which are only available using the pen device in the nonformulary drug.
There are no studies demonstrating superiority of one rapid acting insulin analog over another. The patient needs half unit increments. This is only available in the pen device that is being requested. It is not available in the formulary alternatives. The request is consistent with generally accepted standards of medical practice.