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fluticasone propionate nasal exhaler — Blue Cross Blue Shield of Montana

other FDA labeled indications for the requested agent and route

Initial criteria

  • ALL of the following must be met:
  • 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 prescriber states the patient is currently being treated with the requested agent and the patient is currently stable on the requested agent [chart notes required] OR
  • B. The patient has tried and had an inadequate response to ONE generic or OTC intranasal corticosteroid [chart notes required] OR
  • C. ONE generic or OTC intranasal corticosteroid was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] OR
  • D. The patient has an intolerance or hypersensitivity to ONE generic or OTC intranasal corticosteroid that is not expected to occur with the requested agent [chart notes required] OR
  • E. The patient has an FDA labeled contraindication to ALL generic and OTC intranasal corticosteroids that is not expected to occur with the requested agent [chart notes required] OR
  • F. ONE generic or OTC intranasal corticosteroid is expected to be ineffective or present a significant barrier or safety concern [chart notes required] OR
  • G. ONE generic or OTC intranasal corticosteroid is not in the best interest of the patient based on medical necessity [chart notes required] OR
  • H. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action and it was discontinued for inefficacy or adverse event [chart notes required]
  • AND
  • 4. The patient does NOT have any FDA labeled contraindications to the requested agent
  • Additional allowance for BCBS NM Fully Insured or NM HIM members: rare disease indication, no contraindications, and either FDA labeled or compendia supported indication
  • Additional allowance for Ohio Fully Insured or HIM Shop members: no contraindications and either FDA labeled or compendia supported indication, OR prescriber has submitted two peer-reviewed journal articles supporting proposed use

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process 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

Approval duration

12 months