fluticasone propionate nasal exhaler — Blue Cross Blue Shield of Oklahoma

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 prescriber states the patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent [chart notes are required] OR (B) The patient has tried and had an inadequate response to ONE generic OR OTC intranasal corticosteroid [chart notes are required] OR (C) ONE generic OR OTC intranasal corticosteroid was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required] OR (D) The patient has an intolerance or hypersensitivity to therapy with ONE generic or OTC intranasal corticosteroids that is not expected to occur with the requested agent [chart notes are 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 are required] OR (F) ONE generic OR OTC intranasal corticosteroid is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm [chart notes are required] OR (G) ONE generic OR OTC intranasal corticosteroid is not in the best interest of the patient based on medical necessity [chart notes are 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 and that drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required] AND
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia Allowed: AHFS or DrugDex, 1, 2a, or 2b level of evidence

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