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Drug Category: Cough, Cold and Allergy

Medication Class/Individual Agents: Intranasal Steroids

I. Prior-Authorization Requirements

 Intranasal Corticosteroids

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

azelastine/fluticasone propionate Dymista PA  
beclomethasone nasal aerosol Qnasl PA  
beclomethasone nasal spray Beconase AQ PA  
budesonide OTC nasal spray PA   - > 1 inhaler/month
ciclesonide nasal aerosol, 37 mcg Zetonna PA  
ciclesonide nasal spray, 50 mcg Omnaris PA  
flunisolide nasal spray PA  
fluticasone propionate 50 mcg nasal spray PA   - > 1 inhaler/month
fluticasone propionate 93 mcg nasal spray Xhance PA  
mometasone nasal spray Nasonex PA  
mometasone sinus implant Sinuva PA  
triamcinolone OTC nasal spray Nasacort Allergy 24HR PA   - > 1 inhaler/month

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • Intranasal corticosteroids are effective in managing symptoms of itching, nasal congestion, rhinorrhea, and sneezing associated with perennial and seasonal rhinitis.
  • Symptoms may begin to improve in two to three days but full benefit may not be achieved for two to three weeks.
  • Dosage may be reduced after a response has been achieved.
  • At the recommended doses, side effects are usually minimal and include stinging, sneezing, headache, and epistaxis.
  • Please see the MassHealth Over-the-Counter Drug List for additional information.

FDA-approved ages:

  • ≥ 18 years of age: fluticasone propionate 93 mcg
  • ≥ 12 years of age: ciclesonide 37 mcg nasal aerosol
  • ≥ six years of age: azelastine/fluticasone propionate, beclomethasone nasal spray, budesonide, ciclesonide 50 mcg nasal spray, flunisolide
  • ≥ four years of age: beclomethasone nasal aerosol, fluticasone propionate 50 mcg
  • ≥ two years of age: fluticasone furoate, mometasone, triamcinolone
 
Table Footnotes

II. Therapeutic Uses

FDA-approved, for example:

  • Allergic rhinitis
  • Nasal polyps
  • Nasal polyps and a history of ethmoid sinus surgery
  • Non-allergic rhinitis

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon diagnosis and requested medication (see below).

 

Beconase AQ (1 inhaler/month), brand name Nasonex (1 inhaler/month), flunisolide nasal spray (1 inhaler/month), mometasone nasal spray (1 inhaler/month), Omnaris (1 inhaler/month), Qnasl (1 inhaler/month), and Zetonna (1 inhaler/month) for members six years of age and older

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • an inadequate response (to at least 14 days of use), adverse reaction, or contraindication to budesonide OTC, fluticasone propionate 50 mcg, and Nasacort Allergy 24HR OTC nasal sprays; and
    • requests for brand name Nasonex must meet the above criteria and the prescriber must provide medical records documenting an inadequate response, adverse reaction, or contraindication to the respective generic equivalent

SmartPA: Claims for Beconase AQ, flunisolide nasal spray, mometasone nasal spray, Omnaris, Qnasl, and Zetonna for members ≥ six years will usually process at the pharmacy without a PA request if the claim is for ≤ 1 inhaler per month and the member has a history of paid MassHealth pharmacy claims for budesonide OTC, fluticasone propionate 50 mcg, and Nasacort Allergy 24HR OTC nasal sprays.

 

Beconase AQ (1 inhaler/month), brand name Nasonex (1 inhaler/month), flunisolide nasal spray (1 inhaler/month), mometasone nasal spray (1 inhaler/month), Omnaris (1 inhaler/month), Qnasl (1 inhaler/month), and Zetonna (1 inhaler/month) for members four and five years of age

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • an inadequate response (to at least 14 days of use), adverse reaction, or contraindication to fluticasone propionate 50 mcg and Nasacort Allergy 24HR OTC nasal sprays; and
    • requests for brand name Nasonex must meet the above criteria and the prescriber must provide medical records documenting an inadequate response, adverse reaction, or contraindication to the respective generic equivalent.

Smart PA: Claims for Beconase AQ, flunisolide nasal spray, mometasone nasal spray, Omnaris, Qnasl, and Zetonna for members ages four or five years old will usually process at the pharmacy without a PA request if the claim is for ≤ 1 inhaler per month and the member has a history of paid MassHealth pharmacy claims for fluticasone propionate 50 mcg and Nasacort Allergy 24HR OTC nasal sprays.

 

Beconase AQ (1 inhaler/month), brand name Nasonex (1 inhaler/month), flunisolide nasal spray (1 inhaler/month), mometasone nasal spray (1 inhaler/month), Omnaris (1 inhaler/month), Qnasl (1 inhaler/month), and Zetonna (1 inhaler/month) for members less than four years of age

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • an inadequate response (to at least 14 days of use), adverse reaction or contraindication to Nasacort Allergy 24HR OTC nasal spray; and
    • requests for brand name Nasonex must meet the above criteria and the prescriber must provide medical records documenting an inadequate response, adverse reaction, or contraindication to the respective generic equivalent.

Smart PA: Claims for Beconase AQ, flunisolide nasal spray, mometasone nasal spray, Omnaris, Qnasl, and Zetonna for members < four years old will usually process at the pharmacy without a PA request if the claim is for ≤ 1 inhaler per month and the member has a history of paid MassHealth pharmacy claims for Nasacort Allergy 24HR OTC nasal spray.

 

Beconase AQ (>1 inhaler/month), brand name Nasonex (>1 inhaler/month), Dymista (>1 inhaler/month),  flunisolide nasal spray (>1 inhaler/month), mometasone nasal spray (> 1 inhaler/month), Omnaris (>1 inhaler/month), Qnasl (>1 inhaler/month), Xhance (>1 inhaler/month), and Zetonna (>1 inhaler/month)

  • Documentation of all of the following is required:
    • member must meet age-specific criteria for the individual agent requested (see approval criteria for individual agent above); and
    • medical records demonstrating an inadequate response to an adequate trial of the manufacturer’s recommended doses; and
    • an inadequate response (to at least 14 days of use), adverse reaction, or contraindication to any two of the following: azelastine, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, olopatadine.

 

Dymista (1 inhaler/month)

  • Documentation of all of the following is required:
    • member is ≥ six years of age; and
    • appropriate diagnosis; and
    • an inadequate response (to at least 14 days of use), adverse reaction, or contraindication to azelastine, budesonide OTC, fluticasone propionate 50 mcg, and Nasacort Allergy 24HR OTC nasal sprays; and
    • an inadequate response (to at least 14 days of use), adverse reaction, or contraindication to one second-generation selective antihistamine.

Smart PA: Claims for Dymista for members ≥ six years old will usually process at the pharmacy without a PA request if the claim is for ≤ 1 inhaler per month and the member has a history of paid MassHealth pharmacy claims for azelastine, budesonide OTC, fluticasone propionate 50 mcg, and Nasacort Allergy 24HR OTC nasal sprays, and one second-generation selective antihistamine.

  

fluticasone propionate 50 mcg (> 1 inhaler/month)

  • Documentation of all of the following is required:
    • medical records demonstrating an inadequate response to an adequate trial of the manufacturer’s recommended doses; and
    • an inadequate response (to at least 14 days of use), adverse reaction, or contraindication to any two of the following: azelastine, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, olopatadine.

 

Sinuva

  • Documentation of all of the following is required:
    • member is ≥ 18 years of age; and
    • appropriate diagnosis; and
    • prescriber is an otolaryngologist; and
    • appropriate dosing; and
    • one of the following:
      • an inadequate response or adverse reaction to an oral corticosteroid and an inadequate response (to at least 14 days of use) or adverse reaction to an intranasal corticosteroid; or
      • a contraindication to oral corticosteroids and an inadequate response (to at least 14 days of use) or adverse reaction to two intranasal corticosteroids.

 

Xhance (1 inhaler/month)

  • Documentation of all of the following is required:
    • member is ≥ 18 years of age; and
    • appropriate diagnosis; and
    • medical necessity for use instead of all other intranasal corticosteroids.

  

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans. 


Original Effective Date: 02/2009

Last Revised Date: 08/2019


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Last updated 08/29/19