CurrentColorado Rocky Mountain Health PlansPolicy N/A

Step therapy for Xhance (fluticasone propionate)

This document defines step therapy requirements for coverage of Xhance (fluticasone propionate) for members of Colorado Rocky Mountain Health Plans, requiring trials of lower-cost intranasal steroid alternatives before Xhance is authorized.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyStep therapy for Xhance (fluticasone propionate)

Policy CodePolicy N/A

Change TypeNew step therapy programminor removal

Effective DateOct 1, 2025

Next Review DateJul 1, 2025

Key ActionObtain documented trials (drug name and date) showing failure, contraindication, or intolerance to required intranasal corticosteroids before requesting prior authorization for Xhance.

SourceLink

POLICY UPDATE CHANGES

New step therapy program for Xhance established.

Zetonna was removed from the program.

12 monthsauthorization duration for approved Xhance requests

2 agentsrequired prior intranasal steroid trials for CRSwNP

3 agentsrequired prior intranasal steroid trials for CRSsNP and Other Indications

P&T 7/2024, 7/2025Policy approval/review dates

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Coverage Criteria for Xhance (fluticasone propionate)

Initial Therapy — CRSwNP

Covered when ALL of the following are met

CRSwNP initial approval: Member has chronic rhinosinusitis with nasal polyps and documented history of failure, contraindication, or intolerance to BOTH of the following intranasal corticosteroids: (1) prescription fluticasone nasal spray (generic Flonase) AND (2) prescription mometasone nasal spray (generic Nasonex).

Document date tried for each medication. Authorization duration: 12 months.

Initial Therapy — CRSsNP

Covered when ALL of the following are met

CRSsNP initial approval: Member has chronic rhinosinusitis without nasal polyps and documented history of failure, contraindication, or intolerance to THREE of the following intranasal corticosteroids: (1) budesonide nasal spray (Rhinocort Allergy Spray), (2) fluticasone nasal spray (generic Flonase, Flonase Allergy or Flonase Sensimist), (3) flunisolide nasal spray (generic Nasalide), (4) mometasone nasal spray (generic Nasonex or Nasonex 24H Allergy), (5) triamcinolone nasal spray (Nasacort Allergy 24HR).

Document drug and date tried for each medication. Authorization duration: 12 months.

Initial Therapy — Other Indications

Covered when ALL of the following are met

Other indications initial approval: For other indications, documented history of failure, contraindication, or intolerance to THREE of the following intranasal corticosteroids is required: budesonide nasal spray (Rhinocort Allergy Spray), fluticasone nasal spray (generic Flonase, Flonase Allergy or Flonase Sensimist), flunisolide nasal spray (generic Nasalide), mometasone nasal spray (generic Nasonex or Nasonex 24H Allergy), triamcinolone nasal spray (Nasacort Allergy 24HR).

Document drug and date tried for each medication. Authorization duration: 12 months.

Coverage of Xhance is subject to applicable state mandates, federal regulatory requirements, and the member's specific benefit plan limitations; these may modify or limit coverage even when clinical criteria are met. In addition, other internal policies and utilization management programs may apply and affect authorization decisions. Finally, note that budesonide (generic Rhinocort), triamcinolone (generic Nasacort), and Xhance are typically excluded from coverage under certain plan provisions.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Xhance (fluticasone propionate) will only be approved when the member has a documented history of failure, contraindication, or intolerance to the specified lower-cost intranasal steroid alternatives for the indicated condition. Authorization, when approved, will be issued for 12 months.

Approval requires documentation of the specific drug(s) tried and the date(s) tried.
Authorization period: 12 months.
State mandates, federal requirements, member benefit plan coverage, and other UM programs may affect coverage.
Note: budesonide (Rhinocort), triamcinolone (Nasacort), and Xhance are typically excluded from coverage — check member benefits.

Step Therapy

Step Therapy Requirement

Step therapy requires members to try specified lower-cost intranasal corticosteroids and demonstrate failure, intolerance, or contraindication prior to approval of Xhance. Requirements differ by diagnosis: for chronic rhinosinusitis with nasal polyps the member must fail both fluticasone nasal spray and mometasone nasal spray; for chronic rhinosinusitis without nasal polyps (and other indications) the member must fail three agents from the listed alternatives.

Initial Authorization Requirements

Initial therapy requirements

Initial authorization requirements

CRSwNP step: Require documented history of failure, contraindication, or intolerance to BOTH prescription fluticasone nasal spray (generic Flonase) and prescription mometasone nasal spray (generic Nasonex).2 agents

Document dates tried. Authorization duration: 12 months.

CRSsNP/Other step: Require documented history of failure, contraindication, or intolerance to any THREE agents from: budesonide (Rhinocort Allergy Spray), fluticasone nasal spray (generic Flonase variants), flunisolide (Nasalide), mometasone (Nasonex variants), triamcinolone (Nasacort Allergy 24HR).3 agents

Document drug and date tried. Authorization duration: 12 months.

Reauthorization Criteria

Reauthorization

Reauthorization considerations

Reauthorization: Authorizations are issued for 12 months; reauthorization may be approved based on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic per automated processes and program rules.

Supply limits may apply.

Step Therapy Requirements (Required Trials)

Step	Required prior intranasal corticosteroid trials before Xhance	Authorization duration
CRSwNP (Chronic rhinosinusitis with nasal polyps)	Documented history of failure, contraindication, or intolerance to BOTH: 1) prescription fluticasone nasal spray (generic Flonase®) and 2) prescription mometasone nasal spray (generic Nasonex®). Document date tried for each medication.	12 months
CRSsNP (Chronic rhinosinusitis without nasal polyps)	Documented history of failure, contraindication, or intolerance to ANY THREE of the following (document drug and date tried): budesonide nasal spray (Rhinocort Allergy Spray), fluticasone nasal spray (generic Flonase® / Flonase Allergy / Flonase Sensimist), flunisolide nasal spray (generic Nasalide®), mometasone nasal spray (generic Nasonex® / Nasonex 24H Allergy), triamcinolone nasal spray (Nasacort Allergy 24HR).	12 months
Other indications	Documented history of failure, contraindication, or intolerance to ANY THREE of the same list as CRSsNP (document drug and date tried): budesonide (Rhinocort), fluticasone (Flonase variants), flunisolide (Nasalide), mometasone (Nasonex variants), triamcinolone (Nasacort).	12 months

Quantity and Supply Limits

Xhance — Quantity limits

Quantity limit summarySupply limits may apply to Xhance; plan may enforce per‑plan dispensing or duration limits.

Authorization durationAuthorizations are issued for 12 months (see reauthorization rules).

Basis for limitsSupply limits are part of additional clinical rules and may be applied by automated program logic or plan rules.

ExceptionsNotwithstanding criteria, approvals may occur based on previous claim/medication history or automated processes; limits still may apply.

Definitions

Step therapy — definition and program terms

DefinitionStep therapy program: a utilization management program requiring trials of specified lower‑cost alternatives before coverage of a specified medication (here, Xhance).

Required trials for CRSwNPDocumented history of failure, contraindication, or intolerance to BOTH prescription fluticasone nasal spray and prescription mometasone nasal spray (2 agents) prior to approval.

Required trials for CRSsNP and other indicationsDocumented history of failure, contraindication, or intolerance to any THREE listed intranasal corticosteroids (budesonide, fluticasone nasal spray variants, flunisolide, mometasone, triamcinolone) prior to approval.

Documentation requiredClinical documentation must include the specific drug(s) tried and the date(s) tried to demonstrate failure, contraindication, or intolerance.

Approval pathway exceptionsUnitedHealthcare may approve initial or reauthorization based on previous claim/medication history, diagnosis codes, and/or claim logic per automated processes.

Background

Xhance (fluticasone propionate) is indicated for treatment of chronic rhinosinusitis with and without nasal polyps in adults. The step therapy program requires trials of lower-cost intranasal corticosteroids before Xhance will be authorized: for CRSwNP members, documented failure, contraindication, or intolerance to both prescription fluticasone nasal spray and prescription mometasone nasal spray is required; for CRSsNP and other indications, documented failure, contraindication, or intolerance to three agents from the listed intranasal corticosteroids is required. Prior authorization must include documentation of the specific drug(s) tried and the date(s) tried; when approved, authorizations are issued for 12 months.