CurrentCignaPolicy N/A

Nasal Steroids Step Therapy Policy

Defines step therapy requirements for prescription nasal steroid products administered under Cigna benefit plans; applies to providers and members covered by Cigna companies.

Policy Summary

PayerCigna

PolicyNasal Steroids Step Therapy Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateMay 7, 2025

Key ActionMembers must try one Step 1 product (fluticasone propionate nasal spray) before a Step 2 product will be approved; for patients <4 years, mometasone furoate may be approved.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2therapy steps

1 yearapproval duration

11named Step 2 products

Coverage / Step Therapy Criteria

Step Therapy Criteria

Covered when ALL of the following are met

Policy Summary

PayerCigna

PolicyNasal Steroids Step Therapy Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateMay 7, 2025

Key ActionMembers must try one Step 1 product (fluticasone propionate nasal spray) before a Step 2 product will be approved; for patients <4 years, mometasone furoate may be approved.

SourceLink

On This Page

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Named Prescription Nasal Steroid Products / Codes

Step 1 (Preferred) - CoveredmixedCovered

Fluticasone propionate nasal spray

generic - Step 1 preferred product

Step 2 (Non-preferred / Subject to Step Therapy)mixed

Azelastine HCl/Fluticasone propionate nasal spray (Dymista)	azelastine hydrochloride/fluticasone propionate nasal spray - MEDA, generic
Beconase AQ	beclomethasone nasal spray - GlaxoSmithKline
Flunisolide nasal spray	generic
Mometasone furoate nasal spray	generic
Omnaris	ciclesonide nasal spray - Covis
Qnasl / Qnasl Children's	beclomethasone dipropionate nasal aerosol - Teva
Ryaltris	olopatadine hydrochloride/mometasone furoate nasal spray - Hikma
Xhance	fluticasone propionate EDS (exhalation delivery system) - OptiNose
Zetonna	ciclesonide nasal aerosol - Covis

Provider Requirements and Prior Authorization

Prior Authorization

Coverage Determination for Step 2 Products

Step therapy requirement — Coverage for Step 2 products is determined by the Step Therapy criteria at the point of service. If the Step Therapy rule is not met for a Step 2 product at point of service, coverage will be determined by the Step Therapy criteria. All approvals are provided for 1 year in duration.

Coverage determinations follow the Step Therapy criteria at point of service
Approvals for Step 2 products are provided for 1 year

Step Therapy

Step Therapy Requirement

Members must try one Step 1 product before a Step 2 product will be approved. The designated Step 1 product is fluticasone propionate nasal spray. Special-age exception: if the patient is < 4 years of age, approve mometasone furoate nasal spray.

Step 1 product: fluticasone propionate nasal spray
If patient is < 4 years of age, mometasone furoate nasal spray may be approved without Step 1 trial

Billing Rule

Claims Submission and Billing Guidance

Providers must submit claims and prior authorization requests using the appropriate covered diagnosis and procedure codes and follow the member's benefit plan documentation. Claims submitted without covered codes under the applicable coverage policy will be denied as not covered. Use the most appropriate codes as of the date of submission.

Submit claims with appropriate covered diagnosis and procedure codes
Follow the terms of the applicable benefit plan document and provide required documentation
Claims lacking covered codes under this policy will be denied as not covered

Denial Risk

Coverage Determination Note

Providers should ensure Step Therapy criteria are met at the point of service to avoid denials. Exceptions to the Step Therapy requirement may be considered but any other exception not meeting criteria is considered not medically necessary.

Step 2 coverage is contingent on meeting Step Therapy criteria at point of service
Exceptions process applies; requests not meeting criteria are not medically necessary

Clinical Background

Prescription nasal corticosteroids (excluding Xhance) are used to treat symptoms of seasonal and perennial allergic rhinitis and related nasal inflammatory conditions. Xhance (fluticasone propionate delivered via an exhalation delivery system) is distinct in both its delivery mechanism and its indication for chronic rhinosinusitis with or without nasal polyps in adults. Several prescription products are included in the Step 1/Step 2 framework: Step 1 is fluticasone propionate nasal spray; Step 2 includes named prescription agents such as azelastine/fluticasone (Dymista), beclomethasone (Beconase AQ), flunisolide, mometasone furoate, ciclesonide products (Omnaris, Zetonna), Qnasl, Ryaltris, and Xhance. The policy emphasizes trying a Step 1 product prior to approval of Step 2 products, with age-based exceptions as specified elsewhere in the criteria.

Key Definitions

inv-10: Xhance — indication summary

Generic nameFluticasone propionate nasal spray delivered via an exhalation delivery system (Xhance)

Indication (per FDA / policy)Treatment of chronic rhinosinusitis (CRS) with or without nasal polyps in adults

Delivery systemOptiNose® Exhalation Delivery System (EDS) — bi-directional exhalation delivery differing from traditional nasal sprays

Age groupAdults (FDA indication for CRS ± nasal polyps)

Policy noteXhance is treated as a Step 2 product in the nasal steroid step therapy policy; prescription nasal corticosteroids except Xhance are indicated for SAR/PAR

inv-11: Acronym definitions — SAR, PAR, CRSwNP

SARSeasonal allergic rhinitis

PARPerennial allergic rhinitis

CRSwNPChronic rhinosinusitis with nasal polyps