CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Prior authorization form for select intranasal corticosteroid and combination nasal sprays

This document is a prior authorization request form used by OptumRx for selected nasal steroid and combination nasal spray products (e.g., Beconase AQ, Dymista, Flonase, Nasacort, Omnaris, Qnasl, Rhinocort, Zetonna) and governs how providers submit PA requests for covered members of Blue Cross Blue Shield - South Carolina via OptumRx/CoverMyMeds.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyPrior authorization form for select intranasal corticosteroid and combination nasal sprays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization requests via CoverMyMeds (go.covermymeds.com/OptumRx) or fax to 844-403-1029 with required patient, provider, clinical information, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8products listed on form

2form pages

844-403-1029fax

CoverMyMedsonline portal

855-811-2218

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Coverage Criteria

Initial prior authorization criteria

Covered when ALL of the following are met and documented on the form

Documentation: Provider documents diagnosis and corresponding ICD-10 code(s).

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Dosing conformity: Drug is prescribed within the manufacturer's published dosing guidelines or within dosing guidelines found in accepted compendia or current literature (e.g., package insert, AHFS, Micromedex, current accepted guidelines).

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Formulary trial/failure OR contraindication/adverse reaction: Either (A) patient had trial and failure or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of preferred formulary alternatives for the diagnosis with medication names, dates of trial(s), and reasons for failure(s) documented, OR (B) patient has documented contraindication(s) or documented adverse reaction(s) to the listed formulary alternatives with medication names and reasons documented.

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No available formulary agent: If no listed formulary agent exists for the patient’s clinical condition based on published guidelines or clinical literature, provider documents the clinical condition to justify use of a non‑formulary agent.

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Signature: Prescriber signature and date present on form.

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The prior authorization form covers select intranasal corticosteroid and combination nasal spray products when all required criteria are documented on the form. Approval requires: documentation of the patient’s diagnosis with corresponding ICD‑10 code(s); confirmation that the prescribed dose is within the manufacturer’s or accepted compendia dosing guidelines; documentation of either a trial-and-failure or intolerance to a majority of preferred formulary alternatives (with medication names, dates, and reasons), OR documented contraindication(s) or adverse reaction(s) to listed formulary alternatives; documentation when no formulary agent exists for the patient’s clinical condition based on published guidelines or literature; and the prescriber’s signature and date on the form.

Requests must include all required information and a completed form; this request may be denied unless all required information is received. Providers should ensure the form contains member and provider identification, diagnosis with ICD‑10 code(s), medication details, documentation of prior trials/failures or contraindications/adverse reactions (with dates and reasons), and the prescriber’s signature and date to avoid denial for incomplete submission.

Diagnosis and Billing Codes

Diagnosis codesICD-10

ICD-10 Code(s)

space provided to list ICD-10 diagnosis codes for the requested medication

Provider Actions and Submission Instructions

Note

Submission channels

OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations. Visit go.covermymeds.com/OptumRx to begin using this free service. This form may also be faxed to 844-403-1029.

Online: go.covermymeds.com/OptumRx (CoverMyMeds portal) — recommended for faster processing and potential real-time determinations
Fax: 844-403-1029

Step Therapy

Formulary trial / step therapy requirements

Document trials, failures, intolerances, or contraindications to preferred formulary alternatives. For nasal steroid products, a majority trial typically means two or more agents in the class (or one when only one alternative exists). Include medication names, dates of trial, and reason for failure/intolerance.

Example preferred alternatives: budesonide nasal spray, flunisolide spray, fluticasone spray, triamcinolone spray, mometasone spray
If a contraindication exists, clearly document the specific agent(s) and the contraindication
If an adverse reaction occurred or is reasonably expected, document the agent(s) and the reaction

Background

Intranasal corticosteroids and combination nasal sprays are commonly used to manage allergic and nonallergic rhinitis. The form is intended to confirm appropriate use after failure of, intolerance to, or contraindication to preferred formulary agents by requiring documentation of diagnosis, dosing within accepted guidelines, and prior medication trials or contraindications. When no appropriate formulary agent exists for the clinical condition, the provider must document the condition and justification based on published guidelines or literature; final review considers the submitted clinical rationale along with the required supporting details and prescriber signature.

Definitions

Definition: majority (trial/failure requirement)

Definition'Majority' means two or more agents within a therapeutic class when the class has at least two alternative agents, or one agent when the class contains only a single alternative.

Context for trials/failuresApplies to trials and failures or intolerances of preferred formulary/preferred drug list alternatives for the requested diagnosis (examples listed on the form include budesonide nasal spray, flunisolide spray, fluticasone spray, triamcinolone spray, mometasone spray).

Documentation requiredWhen 'majority' is claimed, the form requires documentation of the medication(s) tried, dates of trial(s), and reason(s) for treatment failure(s).

Adverse reactions/contraindications'Majority' also applies when documenting adverse reactions or contraindications — the form asks for medication names and the specific adverse reaction(s) or contraindication(s).

Use in approval logicSatisfaction of the 'majority' trial/failure requirement (or documented contraindication/adverse reaction to formulary alternatives) is a condition for coverage consideration per the initial prior authorization criteria.