Glucagon
Drug - Glucagon Kit (glucagon for injection) [various manufacturers]
Baqsimi™ (glucagon powder) [Eli Lilly and Company]
Gvoke™ Hypopen (glucagon injection) [Xeris Pharmaceuticals, Inc.]
Gvoke™ Pre-Filled Syringe (glucagon injection) [Xeris Pharmaceuticals, Inc.]
February 2020
Therapeutic area - Glucagon Agents
Approval criteria for Glucagon Kit
- No prior authorization is required
- Quantity limits apply
Approval criteria for Baqsimi
- Patient must be at least 4 years old AND
- Patient has a diagnosis of type 1 or type 2 diabetes AND
- Patient must NOT have pheochromocytoma, an insulinoma, or known hypersensitivity to glucagon or any of the excipients in the product AND
- Prescriber provides documentation to substantiate ALL the following:
- Patient and/or caregiver has been trained to recognize the signs and symptoms of hypoglycemia and has a plan of action to reverse hypoglycemia when it occurs AND
- Patient has been instructed on how to use Baqsimi and how to discard and replace used or unused Baqsimi AND
- Patient has a comprehensive diabetes care plan including self-monitoring of blood glucose or continuous glucose monitoring
Approval criteria for Gvoke
- Patient must be at least 2 years old AND
- Patient has a diagnosis of type 1 or type 2 diabetes AND
- Patient must NOT have pheochromocytoma, an insulinoma, or known hypersensitivity to glucagon or any of the excipients in the product AND
- Prescriber provides documentation to substantiate ALL the following:
- Patient and/or caregiver has been trained to recognize the signs and symptoms of hypoglycemia and has a plan of action to reverse hypoglycemia when it occurs AND
- Patient and/or caregiver has been instructed on how to use Gvoke and how to discard and replace used or unused Gvoke AND
- Patient has a comprehensive diabetes care plan including self-monitoring of blood glucose or continuous glucose monitoring
Quantity limits
- Glucagon Kit: 2 kits per 34 days
- Baqsimi: 2 devices per 34 days
- Gvoke: 2 autoinjectors or 2 prefilled syringes per 34 days
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411
