CurrentAdvanced HealthPolicy N/A

Intranasal Corticosteroids Drug Use Criteria

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This policy governs coverage and prior authorization for intranasal corticosteroids under the Oregon Health Plan, including preferred-agent sequencing, covered diagnoses, formulary exceptions, and least-cost alternative requirements.

Policy Summary

PayerAdvanced Health

PolicyIntranasal Corticosteroids Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse generic fluticasone propionate nasal spray 16 gram first; document trial failure or contraindication before requesting a nonpreferred agent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16 gramsGeneric fluticasone propionate quantity without prior authorization

20 or youngerAge threshold for the younger-member pathway

6 monthsMaximum Nasacort Allergy 24HR approval duration

2Required formulary failures or intolerances for other nonformulary agents

Least costly

Policy Summary

PayerAdvanced Health

PolicyIntranasal Corticosteroids Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse generic fluticasone propionate nasal spray 16 gram first; document trial failure or contraindication before requesting a nonpreferred agent.

SourceLink

On This Page

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CurrentAdvanced HealthPolicy N/A

Intranasal Corticosteroids Drug Use Criteria

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Sign up for all advancedhealth policy alerts

Know when advancedhealth releases new policies or updates existing guidance.

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Policy Summary

PayerAdvanced Health

PolicyIntranasal Corticosteroids Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse generic fluticasone propionate nasal spray 16 gram first; document trial failure or contraindication before requesting a nonpreferred agent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16 gramsGeneric fluticasone propionate quantity without prior authorization

20 or youngerAge threshold for the younger-member pathway

6 monthsMaximum Nasacort Allergy 24HR approval duration

2Required formulary failures or intolerances for other nonformulary agents

Least costly

Policy Summary

PayerAdvanced Health

PolicyIntranasal Corticosteroids Drug Use Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse generic fluticasone propionate nasal spray 16 gram first; document trial failure or contraindication before requesting a nonpreferred agent.

SourceLink

On This Page

Nonformulary cost rule

Coverage Criteria

Initial therapy and medical necessity

Coverage requires the following sequential criteria:

Initial coverage requirements

Preferred fluticasone requirement: There has been a trial and failure or contraindication to preferred fluticasone propionate 16 gram.
Trial, failure, or contraindication to fluticasone propionate is required before progression to other agents.
Age and diagnosis pathway
- Age 20 or younger: The member is 20 years of age or younger.<=20 years
  Proceed to the clinical-rationale step.
- Age over 20 funded-diagnosis pathway
  - Funded condition or covered comorbidity: The patient has chronic sinusitis, acute sinusitis, or sleep apnea for which substantial evidence supports intranasal corticosteroid use; alternatively, the patient has asthma, reactive airway disease, or a covered comorbid condition.
    Off-label use is not a covered benefit of the Oregon Health Plan. Evidence is insufficient to support use for COPD.
Clinical rationale and agent selection: There is a clinical rationale for use of a nonformulary agent, such as documented intolerance to a formulary agent.
For Nasacort Allergy 24HR, approval may be issued for the requested duration up to 6 months. For another nonformulary agent, failure or intolerance to both fluticasone propionate and Nasacort Allergy 24HR must be substantiated in the chart note and prescription fill history, followed by review of the next least costly option.

Nonformulary exception

Nonformulary exceptions are covered only when all requirements are met:

Nonformulary exception: There is a clinical rationale for the nonformulary agent; for an agent other than Nasacort Allergy 24HR, failure or intolerance to both fluticasone propionate and Nasacort Allergy 24HR is substantiated in the chart note and prescription fill history; and the next least costly intranasal corticosteroid alternative is prescribed.

For Nasacort Allergy 24HR, approval may be issued for the requested duration up to 6 months. For other nonformulary agents, approval is available for 6 months only when the next least costly alternative is prescribed; otherwise, the request does not meet the Oregon Health Plan least-cost alternative rule.

Use of intranasal corticosteroids for COPD is not supported by sufficient evidence under this policy and does not meet coverage criteria.

Off-label use of intranasal corticosteroids is not a covered Oregon Health Plan benefit. Coverage requires a supported, funded indication that meets the policy criteria.

Requests do not meet coverage criteria unless there is a documented trial and failure or contraindication to preferred fluticasone propionate 16 gram. This preferred-agent requirement must be satisfied before progression to other agents.

For members older than 20 years, an above-the-line diagnosis must be supported by substantial evidence and accompanied by a funded condition, such as chronic sinusitis, acute sinusitis, or sleep apnea, or by asthma, reactive airway disease, or another covered comorbid condition. Requests that do not meet these diagnosis requirements do not meet coverage criteria.

A nonformulary request must include a clinical rationale and substantiated failure or intolerance to both fluticasone propionate and Nasacort Allergy 24HR in the chart note and prescription fill history. The next least costly intranasal corticosteroid must be prescribed; otherwise, the request does not meet the Oregon Health Plan least-cost alternative requirement.

Initial Therapy

Generic fluticasone propionate first line

Preferred-agent sequencing applies to initial therapy:

Preferred initial therapy: Use generic fluticasone propionate nasal spray first, unless the member has a documented trial failure or contraindication.16 grams

Generic fluticasone propionate nasal spray, 16 gram only, is covered without prior authorization. Nasacort Allergy 24HR may be considered second line for members unable to tolerate generic fluticasone who meet the drug use criteria.

Step Therapy Sequence

Step	Agent	Coverage / requirement
1	Generic fluticasone propionate nasal spray, 16 gram	First-line therapy; covered without prior authorization. A trial and failure or contraindication is required before progression to another agent.

Step	Agent	Coverage / requirement
2	Nasacort Allergy 24HR (triamcinolone)	May be considered as the second-line agent for members unable to tolerate generic fluticasone propionate who meet the drug use criteria; approval may be issued for up to 6 months when criteria are met.

Quantity Limits

Quantity limit

MedicationGeneric fluticasone propionate nasal spray

Covered quantity limit16 grams per course

Prior authorizationCovered without prior authorization

Prior Authorization and Documentation

Prior Authorization

Prior Authorization for Nonpreferred Agents

Generic fluticasone propionate nasal spray 16 gram is covered without prior authorization. Requests for other intranasal corticosteroids require review under the preferred-agent and drug-use criteria.

Use generic fluticasone propionate 16 gram as the preferred agent.
Document a trial and failure or a contraindication before requesting a nonpreferred agent.

Prior Authorization

Nasacort Allergy 24HR Exception

Nasacort Allergy 24HR (triamcinolone) may be considered as a second-line agent when the member cannot tolerate generic fluticasone and the applicable coverage criteria are met. When clinical rationale supports the request, approve for the requested duration of therapy up to 6 months.

Document the clinical rationale, such as intolerance to the formulary agent.
Confirm that the request is for Nasacort Allergy 24HR and that the indication meets coverage criteria.

Coverage Definitions

Above-the-line diagnosis

DefinitionA diagnosis for which a substantial body of evidence supports use of intranasal corticosteroids and which is funded for coverage under the applicable Oregon Health Plan criteria.

Evidence requirementSubstantial evidence must support use of intranasal corticosteroids.

Coverage statusThe diagnosis is funded for coverage under the applicable Oregon Health Plan criteria.

Below-the-line diagnosis

DefinitionA diagnosis for which use of intranasal corticosteroids does not meet the funded coverage criteria.

Coverage outcomeRequests for a below-the-line diagnosis do not meet criteria.

Clinical Background

Intranasal corticosteroids are used for allergic and non-allergic rhinitis, with FDA-approved indications that vary by product and age. Applicable products may also have FDA-approved indications for nasal polyps. Under this policy, coverage supports funded conditions such as asthma-related disease, sinusitis, and obstructive sleep apnea when the required criteria are met. Because the evidence does not establish meaningful differences in comparative effectiveness, efficacy, or safety among formulations for the covered outcomes addressed by the policy, the least costly formulation is favored.

Billing Rule

Nonformulary Least-Cost Review

For a nonformulary agent other than Nasacort Allergy 24HR, the chart note and prescription fill history must substantiate documented failure or intolerance to both generic fluticasone propionate and Nasacort Allergy 24HR. Compare intranasal steroid prices and recommend the next least costly option; approve for 6 months only when that option is prescribed, otherwise deny under the OHP least-cost alternative rule.

Require chart-note and prescription-fill-history support for both preferred-agent failures or intolerances.
Perform a price comparison and document the recommended least costly alternative.
Deny when the next least costly alternative is not prescribed.

Step Therapy

Preferred-Agent Sequence

Follow the preferred-agent sequence: use generic fluticasone propionate 16 gram first. Nasacort Allergy 24HR may be used as a possible second-line option for members unable to tolerate generic fluticasone; other nonformulary agents require substantiated failure or intolerance to both agents and least-cost review.

First line: generic fluticasone propionate 16 gram.
Second line: Nasacort Allergy 24HR when clinically justified.
Subsequent nonformulary therapy: only after documented failure or intolerance to both prior agents.

Documentation Required

Required Formulary Exception Documentation

For every nonpreferred or nonformulary request, document the preferred-agent trial, failure or contraindication, and the clinical rationale for the requested agent. For nonformulary therapy, include the supporting chart notes and prescription fill history required to substantiate the formulary failure or intolerance.

Document trial and failure or contraindication for generic fluticasone propionate 16 gram.
State the clinical rationale for using a nonformulary agent.
Include chart-note and prescription-fill-history evidence when required.

Denial Risk

Failure to Meet Formulary and Funded-Condition Criteria

Deny the request when the required preferred-agent trial, failure, or contraindication is missing; when the diagnosis is unsupported or below the funded line; or when documentation is insufficient. Off-label use is not a covered Oregon Health Plan benefit, and members older than 20 must meet the applicable evidence-based and funded-condition criteria.

A member age 20 or younger may proceed to the later clinical-rationale review step.
For older members, confirm an above-the-line diagnosis supported by substantial evidence.
Deny when the request does not meet the diagnosis, funded-condition, documentation, or least-cost requirements.

Denial Risk

Unsupported or Unfunded Indication

Intranasal corticosteroids are covered when used for Oregon Health Plan-funded conditions with substantial evidence of benefit. Treatment of allergic or non-allergic rhinitis is funded only when it exacerbates asthma, sinusitis, or obstructive sleep apnea; evidence is insufficient to support intranasal corticosteroid use for COPD.

Qualifying funded conditions include chronic sinusitis, acute sinusitis, and sleep apnea; asthma, reactive airway disease, or another covered comorbid condition may also support coverage when criteria are met.
Do not approve COPD treatment on the basis of the available evidence.
For asthma-related outcomes, obstructive sleep apnea, acute sinusitis, and chronic rhinosinusitis, cover the least costly formulation because comparative evidence among formulations is insufficient.

Related requirementFor members older than 20, the diagnosis must be above the coverage line and supported by substantial evidence.

Funded rhinitis coverage

Covered conditionAllergic or non-allergic rhinitis

Funding requirementRhinitis is funded only when it exacerbates asthma, sinusitis, or obstructive sleep apnea.

Coverage limitationRhinitis without exacerbation of asthma, sinusitis, or obstructive sleep apnea is not funded under this policy.