Asset Publisher
Nasal Inhalers Quantity Limit Program Summary
Policy Number: PH-91190
This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
4/1/2024 |
|
FDA APPROVED INDICATIONS AND DOSAGE
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
Azelastine HCl Nasal Spray 0.1% (137 MCG/SPRAY) |
0.1 % ; 137 MCG/SPRAY |
2 |
Bottles |
30 |
DAYS |
|
|
|
|
Flunisolide Nasal Soln 25 MCG/ACT (0.025%) |
0.025 % |
3 |
Bottles |
30 |
DAYS |
|
|
|
|
Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY) |
0.03 % |
2 |
Bottles |
30 |
DAYS |
|
|
|
|
Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) |
0.06 % |
3 |
Bottles |
30 |
DAYS |
|
|
|
Allergy nasal spray 24 ho ; Allergy relief ; Clarispray ; Cvs fluticasone propionat ; Cvs fluticasone propriona ; Eq allergy relief ; Eql fluticasone propionat ; Flonase allergy relief ; Flonase allergy relief ch ; Ft allergy relief 24 hr ; Gnp fluticasone propionat ; Goodsense 24-hour allergy ; Hm allergy relief nasal s ; Kls aller-flo ; Qc allergy relief ; Sm allergy relief nasal s |
fluticasone propionate nasal susp |
50 MCG/ACT |
1 |
Bottle |
30 |
DAYS |
|
|
|
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
2 |
Bottles |
30 |
DAYS |
|
|
|
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
2 |
Bottles |
30 |
DAYS |
|
|
|
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
2 |
Bottles |
30 |
DAYS |
|
|
|
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
2 |
Bottles |
30 |
DAYS |
|
|
|
Beconase aq |
Beclomethasone Dipropionate Monohyd Nasal Susp 42 MCG/SPRAY |
42 MCG/SPRAY |
2 |
Inhalers |
30 |
DAYS |
|
|
|
Dymista |
Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT |
137-50 MCG/ACT |
1 |
Bottle |
30 |
DAYS |
|
|
|
Dymista |
Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT |
137-50 MCG/ACT |
1 |
Bottle |
30 |
DAYS |
|
|
|
Nasonex 24hr |
Mometasone Furoate Nasal Susp 50 MCG/ACT |
50 MCG/ACT |
2 |
Bottles |
30 |
DAYS |
|
|
|
Nasonex 24hr |
Mometasone Furoate Nasal Susp 50 MCG/ACT |
50 MCG/ACT |
2 |
Bottles |
30 |
DAYS |
|
|
|
Omnaris |
Ciclesonide Nasal Susp 50 MCG/ACT |
50 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
Patanase |
Olopatadine HCl Nasal Soln 0.6% |
0.6 % |
1 |
Bottle |
30 |
DAYS |
|
|
|
Patanase |
Olopatadine HCl Nasal Soln 0.6% |
0.6 % |
1 |
Bottle |
30 |
DAYS |
|
|
|
Patanase |
Olopatadine HCl Nasal Soln 0.6% |
0.6 % |
1 |
Bottle |
30 |
DAYS |
|
|
|
Qnasl |
Beclomethasone Dipropionate Nasal Aerosol 80 MCG/ACT |
80 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
Qnasl childrens |
Beclomethasone Dipropionate Nasal Aerosol 40 MCG/ACT |
40 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
Ryaltris |
Olopatadine HCl-Mometasone Furoate Nasal Susp |
665-25 MCG/ACT |
1 |
Bottle |
30 |
DAYS |
|
|
|
Zetonna |
Ciclesonide Nasal Aerosol Soln 37 MCG/ACT (50 MCG/Valve) |
37 MCG/ACT |
1 |
Inhaler |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
Azelastine HCl Nasal Spray 0.1% (137 MCG/SPRAY) |
0.1 % ; 137 MCG/SPRAY |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Flunisolide Nasal Soln 25 MCG/ACT (0.025%) |
0.025 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY) |
0.03 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) |
0.06 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Allergy nasal spray 24 ho ; Allergy relief ; Clarispray ; Cvs fluticasone propionat ; Cvs fluticasone propriona ; Eq allergy relief ; Eql fluticasone propionat ; Flonase allergy relief ; Flonase allergy relief ch ; Ft allergy relief 24 hr ; Gnp fluticasone propionat ; Goodsense 24-hour allergy ; Hm allergy relief nasal s ; Kls aller-flo ; Qc allergy relief ; Sm allergy relief nasal s |
fluticasone propionate nasal susp |
50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Astepro ; Astepro childrens |
Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY) |
0.15 % ; 205.5 MCG/SPRAY |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Beconase aq |
Beclomethasone Dipropionate Monohyd Nasal Susp 42 MCG/SPRAY |
42 MCG/SPRAY |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dymista |
Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT |
137-50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Dymista |
Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT |
137-50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nasonex 24hr |
Mometasone Furoate Nasal Susp 50 MCG/ACT |
50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nasonex 24hr |
Mometasone Furoate Nasal Susp 50 MCG/ACT |
50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Omnaris |
Ciclesonide Nasal Susp 50 MCG/ACT |
50 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Patanase |
Olopatadine HCl Nasal Soln 0.6% |
0.6 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Patanase |
Olopatadine HCl Nasal Soln 0.6% |
0.6 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Patanase |
Olopatadine HCl Nasal Soln 0.6% |
0.6 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qnasl |
Beclomethasone Dipropionate Nasal Aerosol 80 MCG/ACT |
80 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qnasl childrens |
Beclomethasone Dipropionate Nasal Aerosol 40 MCG/ACT |
40 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ryaltris |
Olopatadine HCl-Mometasone Furoate Nasal Susp |
665-25 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zetonna |
Ciclesonide Nasal Aerosol Soln 37 MCG/ACT (50 MCG/Valve) |
37 MCG/ACT |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
ALBP _ Commercial _ PS _ Nasal_Inhalers_QL _ProgSum_ 04-01-2024