Download Prior Authorization Criteria Nasal Sprays Drugs: Beconase AQ

Prior Authorization Criteria
Nasal Sprays
Drugs: Beconase AQ (beclomethasone dipropionate)
Dymista (azelastine/fluticasone)
Olopatadine 0.6%
Omnaris (ciclesonide)
Patanase (olopatadine)
Qnasl (beclomethasone dipropionate)
Veramyst (fluticasone)
Zetonna (ciclesonide)
P&T Reviewed: 2/16, 5/16
Last Revised: 4/16, 5/16
This Document applies to Freedom Drug List Members ONLY
(Connecticut Exchange members and most ConnectiCare SOLO Plan members)
Description:
Beconase AQ, Omnaris, Qnasl, Veramyst and Zetonna: are intranasal steroids, used for the relief of
symptoms of seasonal or perennial allergic and non-allergic (vasomotor) rhinitis.
Dymista: is a combination of an antihistamine and a steroid, used for the relief of symptoms of seasonal
allergic rhinitis in patients 6 years and older
Olopatadine (Patanase): is an antihistamine used for the relief of symptoms of seasonal allergic rhinitis
in patients 6 years and older
Criteria:
The above listed drugs are covered only if the following prior authorization criteria is met:
•
•
The requested medication is to be used for its FDA-approved diagnosis
The patient has had an intolerance to, or treatment failure of, a trial of two of the following
medications
o Azelastine (Astelin, Astepro)
o Budesonide AQ (Rhinocort AQ)
o Flunisolide (Nasalide)
o Fluticasone (Flonase)
o Mometasone furoate (Nasonex)
o Triamcinolone (Nasacort AQ)
Plan Limitations: If the above criteria are met approval may be granted for up to one year
The above criteria is based on the following reference(s):
1.
Facts & Comparisons Online