ModifiedBlue Cross Blue Shield - IowaPolicy 05.01.78

Intranasal Steroids and Combination Products

Defines medical necessity criteria for coverage of specified prescription intranasal corticosteroids and a combination product (Ryaltris) versus OTC intranasal corticosteroids, approval durations, and noncoverage when criteria not met for Wellmark Blue Cross and Blue Shield members.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyIntranasal Steroids and Combination Products

Policy CodePolicy 05.01.78

Change TypeReviewed and revised

Effective DateMay 14, 2026

Next Review Date

Key ActionRequests for listed prescription intranasal corticosteroids, Qnasl Childrens, and Ryaltris require meeting the documented medical necessity criteria; approvals are granted for 24 months.

POLICY UPDATE CHANGES

Policy reviewed and revised in April 2026 with current effective date May 14, 2026.

3Covered Indication Pathways

24Approval Duration (months)

5Named Prescription Agents

Coverage Summary

This coverage policy defines medical necessity criteria for specified prescription intranasal corticosteroids and a combination product and is covered_with_criteria. Named prescription agents include Beconase AQ, Omnaris, Qnasl, Qnasl Childrens, Zetonna, and Ryaltris (mometasone + olopatadine). The policy intends to encourage use of OTC intranasal corticosteroid agents prior to prescribing these listed prescription products when clinically appropriate due to therapeutic interchangeability. Approvals for covered agents are granted for 24 months. The policy effective date is May 14, 2026.

Medical Necessity Criteria

I. Beconase AQ, Omnaris, Qnasl, Qnasl Childrens, Zetonna, and generic equivalents (patients >= 6 years)

Considered medically necessary when ALL of the following are met:

ALL of the following

Patient is 6 years of age or older
Patient has an inadequate response, contraindication, or adverse reaction to ALL OTC intranasal corticosteroids: Flonase Allergy Relief, Flonase Sensimist, Nasacort Allergy 24HR, Nasonex 24HR Allergy, AND Rhinocort OTC
Exception if patient is currently receiving a positive therapeutic outcome on the requested medication through health insurance (samples or manufacturer's patient assistance program do not qualify)

II. Qnasl Childrens and generic equivalents (patients < 6 years)

Considered medically necessary when ALL of the following are met:

ALL of the following

Patient is younger than 6 years of age
Patient has an inadequate response, contraindication, or adverse reaction to ALL of the following OTC intranasal corticosteroids: Flonase Allergy Relief, Flonase Sensimist, Nasonex 24HR Allergy, AND Nasacort Allergy 24HR
Exception if patient is currently receiving a positive therapeutic outcome on the requested medication through health insurance (samples or manufacturer's patient assistance program do not qualify)

III. Ryaltris (patients >= 12 years) for seasonal allergic rhinitis

Considered medically necessary when ALL of the following are met:

ALL of the following

Patient is 12 years of age or older
Diagnosis: seasonal allergic rhinitis
Patient must have a medical justification for why they cannot take intranasal olopatadine and intranasal mometasone separately (e.g., intolerance or contraindication to an inactive ingredient in both intranasal olopatadine and intranasone separately)

IV. Not Medically Necessary

The following are considered not medically necessary:

ANY of the following

Beconase AQ, Ryaltris, Omnaris, Qnasl, Qnasl Childrens, Zetonna, and their generic equivalents for patients who do not meet the criteria set forth in sections I–III

Provider Actions & Authorization

Prior Authorization

Prior authorization requirement for covered agents

Requests for listed prescription intranasal corticosteroids, Qnasl Childrens, and Ryaltris require meeting the documented medical necessity criteria; approvals are granted for 24 months.

Approvals are granted for 24 months.
Affected agents: Beconase AQ, Ryaltris, Omnaris, Qnasl, Qnasl Childrens, Zetonna and generics

Documentation Required

Documentation of prior OTC trial or contraindication

Providers must document inadequate response, contraindication, or adverse reaction to all specified OTC intranasal corticosteroids (listed by name) or document current positive therapeutic outcome via health insurance for the requested medication; samples and manufacturer's patient assistance program supplies do not satisfy the OTC trial requirement.

OTC intranasal corticosteroids: Flonase Allergy Relief, Flonase Sensimist, Nasacort Allergy 24HR, Nasonex 24HR Allergy, Rhinocort OTC
Exception: current positive therapeutic outcome via health insurance qualifies; samples and manufacturer's patient assistance program supplies do not qualify

Denial Risk

Denial if criteria not met

Claims for Beconase AQ, Ryaltris, Omnaris, Qnasl, Qnasl Childrens, Zetonna, and generics will be considered not medically necessary and denied if the specific criteria are not met.

Claims for the named agents will be denied if criteria I–III are not met.

Background

Background: The policy rationale is to encourage use of OTC intranasal steroid agents prior to prescription intranasal steroid or combination products because of the high degree of therapeutic interchangeability within the class. The document lists the prescription intranasal steroid agents Beconase AQ, Omnaris, Qnasl, Qnasl Childrens, Zetonna (and generic equivalents) as agents that provide anti-inflammatory effects and manage symptoms of itching, nasal congestion, rhinorrhea, and sneezing associated with perennial and seasonal rhinitis. It also names the combination product Ryaltris (mometasone + olopatadine) with the clinical indication for seasonal allergic rhinitis (Ryaltris indicated for patients 12 years and older when criteria are met).

Definitions: OTC intranasal corticosteroids referenced in this policy specifically include Flonase Allergy Relief, Flonase Sensimist, Nasacort Allergy 24HR, Nasonex 24HR Allergy, and Rhinocort OTC (as applicable per age group) and are the products members must try (or have contraindication/adverse reaction) prior to coverage of the listed prescription agents.

OpenPayer

Intranasal Steroids and Combination Products

Coverage Summary

Medical Necessity Criteria

Provider Actions & Authorization

Coding Guidance

Background

Revision History