Xhance — Blue Cross Blue Shield of Kansas

chronic rhinosinusitis with nasal polyps (CRSwNP)

Initial criteria

1. ONE of the following: A. The patient has a diagnosis of chronic rhinosinusitis with nasal polyps (CRSwNP) OR B. The patient has a diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) OR C. The patient has another FDA labeled indication for the requested agent and route of administration OR D. The patient has another indication that is supported in compendia for the requested agent and route of administration AND
2. If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR B. There is support for using the requested agent for the patient’s age for the requested indication AND
3. ONE of the following: A. The patient has tried and had an inadequate response after 90 days of therapy with ONE generic OR OTC intranasal corticosteroid OR B. The patient has an intolerance or hypersensitivity to therapy with ONE generic or OTC intranasal corticosteroid that is not expected to occur with the requested agent OR C. The patient has an FDA labeled contraindication to ALL generic AND OTC intranasal corticosteroids that is not expected to occur with the requested agent AND
4. The patient does NOT have any FDA labeled contraindications to the requested agent

1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process [Note: patients not previously approved for the requested agent will require initial evaluation review] AND
2. The patient has had clinical benefit with the requested agent AND
3. The patient does NOT have any FDA labeled contraindications to the requested agent

12 months