Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Apidra insulin glulisine 100 unit/mL Solution   Not Applicable Humalog insulin lispro 100 unit/mL Cartridge     $$$$$ Humalog insulin lispro 100 unit/mL Solution     $$$$$ Humalog KwikPen insulin lispro 100 unit/mL Insulin Pen     $$$$$ Humalog Mix 50-50 insulin lispro protam & lispro Insulin Pen     $$$$$ Humalog Mix 50-50 insulin lispro protam & lispro Suspension     $$$$$ Humalog Mix 50-50 KwikPen insulin lispro protam & lispro Insulin Pen     $$$$$ Humalog Mix 75-25 insulin lispro protam & lispro 100 unit/mL (75-25) Suspension     $$$$$ Humalog Mix 75-25 insulin lispro protam & lispro Insulin Pen     $$$$$ Humalog Mix 75-25 KwikPen insulin lispro protam & lispro Insulin Pen     $$$$$ HumaPen Luxura HD insulin admin supplies Insulin Pen     Not Applicable HumaPen Memoir insulin admin supplies Insulin Pen   Not Applicable Humulin 70/30 insulin NPH & regular human 100 unit/mL (70-30) Suspension     $$$ Humulin 70/30 Pen insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen     $$$ Humulin N NPH insulin human recomb 100 unit/mL Suspension     $$$ Humulin N Pen NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen     $$$ Humulin R insulin regular human 100 unit/mL Solution     $$$ Humulin R U-500 Concentrated insulin regular hum U-500 conc 500 unit/mL Solution     $$$ Lantus insulin glargine 100 unit/mL Solution   $$$ Lantus Solostar insulin glargine 100 unit/mL (3 mL) Insulin Pen   $$$$ Levemir insulin detemir Solution     $$$ Novolin 70/30 insulin NPH & regular human 100 unit/mL (70-30) Cartridge   Not Applicable Novolin 70/30 insulin NPH & regular human 100 unit/mL (70-30) Suspension   Not Applicable Novolin N NPH insulin human recomb 100 unit/mL Cartridge   Not Applicable Novolin N NPH insulin human recomb 100 unit/mL Suspension   Not Applicable Novolin R Novolin R 100 unit/mL Cartridge   Not Applicable Novolin R insulin regular human 100 unit/mL Solution   Not Applicable Novolog insulin aspart 100 unit/mL Solution   Not Applicable Novolog Mix 70-30 insulin asp prt-insulin aspart 100 unit/mL (70-30) Cartridge   Not Applicable Novolog Mix 70-30 insulin asp prt-insulin aspart 100 unit/mL (70-30) Solution   Not Applicable Novolog Mix 70-30 FlexPen insulin asp prt-insulin aspart 100 unit/mL (70-30) Insulin Pen   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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