Intranasal Steroids – Essential Formulary

Restricted Product(s):

Restriction applies to brand and generic products

• Beconase AQ® (betamethasone) nasal suspension
• Dymista® (azelastine-fluticasone) nasal spray
• Flunisolide 0.025% nasal solution
• Nasonex® (mometasone furoate) nasal suspension
• OmnarisTM (ciclesonide) nasal suspension
• QnaslTM (beclomethasone) nasal aerosol
• RyaltrisTM (olopatadine and mometasone) nasal suspension
• ZetonnaTM (ciclesonide) nasal aerosol

FDA Approved Use:

• For the management of nasal symptoms of seasonal or perennial rhinitis
• For the prevention of recurrence of nasal polyps following surgical removal in adults and children 6 years and older (Beconase AQ)

Criteria for Approval of Restricted Product(s):

1. The patient has tried and failed TWO over-the-counter intranasal steroids (e.g., fluticasone nasal spray, triamcinolone nasal aerosol, etc.); OR
2. The patient has a clinical intolerance/contraindication to ALL over-the-counter intranasal steroids; AND
3. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval:

365 days (1 year)

References:

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information:

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q4 annually.

January 2023: Criteria update: Added Dymista to policy.

September 2022: Criteria update: Added new to market Ryaltris to policy.

April 2022: Criteria update: Added Beconase AQ, Omnaris, Qnasl and Zetonna to policy.

July 2021: Original utilization management criteria issued.