fluticasone propionate nasal exhaler — Blue Cross Blue Shield of New Mexico

Initial criteria

• 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
• 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
• 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 therapy with ONE generic or OTC intranasal corticosteroid not expected with the requested agent [chart notes required] OR E. The patient has an FDA labeled contraindication to ALL generic AND OTC intranasal corticosteroids not expected with the requested agent [chart notes required] OR F. ONE generic OR OTC intranasal corticosteroid is expected to be ineffective or cause barriers to adherence or worsen a comorbid condition, etc. [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 as ONE generic or OTC intranasal corticosteroid that was discontinued due to lack of efficacy or adverse event [chart notes required]
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• The patient has had clinical benefit with the requested agent
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months