CurrentMass General Brigham Health PlanPolicy N/A

Fluticasone propionate HFA prior authorization for members ≥12 years

This policy governs prior authorization, coverage criteria, and quantity/renewal limits for fluticasone propionate HFA under the pharmacy benefit for Mass General Brigham Health Plan members aged 12 years and older.

Policy Summary

PayerMass General Brigham Health Plan

PolicyFluticasone propionate HFA prior authorization for members ≥12 years

Policy CodePolicy N/A

Change TypeClarified age-based coverageadded transition clause

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for members aged 12 and older and document asthma diagnosis plus trials or contraindications to Arnuity Ellipta and QVAR Redihaler.

SourceLink

POLICY UPDATE CHANGES

Members 12 years of age and older require prior authorization for fluticasone propionate HFA; members through 11 years are covered without this requirement.

Authorization may be granted for members new to the plan within the last 90 days who are currently receiving treatment with the requested medication.

12 monthsapproval duration

≥12PA required for

≤11covered without PA

Coverage and Medical Necessity Criteria

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Initial Authorization Criteria

Authorization may be granted when ALL of the following are met:

Main authorization rule: All of the following must be satisfied

Diagnosis: Member has a diagnosis of asthma

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Prior therapy to preferred brands: Member has had inadequate response, adverse reaction, or contraindication to BOTH preferred brands: Arnuity Ellipta AND QVAR Redihaler

Step therapy requirement; both must be tried or contraindicated [[chunk 4]]

MDI with spacer necessity: Documentation confirming the member requires a metered dose inhaler used with a spacer device due to at least one of: physical dexterity limitation, inadequate inspiratory flow, or cognitive status1 of 3

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Continuation of Therapy

Reauthorization (Continuation of Therapy):

Reauthorization conditions: Initial criteria are met AND member has had a positive clinical response to therapy

Requests for reauthorization approved when positive clinical response documented [[chunk 5]]

Fluticasone propionate HFA is an inhaled corticosteroid formulated for maintenance (prophylactic) treatment of asthma and is not indicated for relief of acute bronchospasm. Acute (rescue) use is outside the approved indication and therefore acute use is not covered under this policy.

Use of fluticasone propionate HFA for relief of acute bronchospasm (rescue therapy) is not medically necessary because the medication is not indicated for acute symptom relief.

Provider Requirements and Prior Authorization Procedures

Prior Authorization

Prior Authorization Required

Prior authorization is required for members aged 12 years and older. For members new to the plan (within 90 days), prior authorization may be granted if documentation shows the member is currently receiving the requested medication (do not accept samples or medications obtained through manufacturer patient assistance programs as evidence of current therapy).

Applies to members 12 years and older
Transition-of-care: approve if member new to plan (<= 90 days) is currently receiving medication; exclude samples and patient assistance program supplies

Step Therapy

Step Therapy Requirement

Step therapy requires documentation of inadequate response, adverse reaction, or contraindication to BOTH preferred products listed below before the requested therapy will be approved.

Preferred products that must be tried and failed (or contraindicated): Arnuity Ellipta; QVAR RediHaler

Documentation Required

Documentation Requirements

Provide clinical documentation to support the request. Required elements include: diagnosis of asthma; documentation of trials and either inadequate response, adverse reaction, or contraindication to both preferred products; and any supporting clinical notes or test results. If the member requires a metered dose inhaler used with a spacer device, include documentation of the reason (physical dexterity limitation, inadequate inspiratory flow, or cognitive status impairment).

Diagnosis: asthma
Trials/Failures or contraindications to BOTH preferred products (Arnuity Ellipta and QVAR RediHaler)
If MDI + spacer required: document one or more of — impaired physical dexterity, inadequate inspiratory flow, or cognitive impairment
For new-to-plan members (≤ 90 days): documentation confirming member is currently receiving the medication (exclude samples/PAP)

Denial Risk

Denial Triggers for Missing Required Criteria

Requests missing any required elements should be denied. Common denial triggers include: no documented diagnosis of asthma; absence of documentation of trials and inadequate response/adverse reaction/contraindication to BOTH preferred products; missing evidence that the member is currently receiving the medication for members new to the plan; and lack of documentation supporting need for an MDI with spacer when claimed.

Deny if no diagnosis of asthma documented
Deny if no documentation of trials/failures or contraindications to BOTH preferred products (Arnuity Ellipta and QVAR RediHaler)
Deny new-member requests if documentation does not confirm current receipt of medication (samples/PAP not acceptable)
Deny if no documentation supporting need for MDI + spacer when indicated

Definitions and Related Terms

Fluticasone HFA

DefinitionFluticasone propionate HFA is an inhaled corticosteroid indicated for maintenance (prophylactic) treatment of asthma in patients aged 4 years and older.

Not for acute bronchospasmFluticasone propionate HFA is NOT indicated for relief of acute bronchospasm (rescue therapy) and such use is not covered.

Coverage scopePolicy restricts prior authorization requirement to members 12 years and older; younger children through 11 are covered without prior auth.

MDI with spacer necessity

Clinical indication for MDI+spacerMDI with spacer is required when documentation shows the member needs a metered dose inhaler with a spacer due to physical dexterity limitations.

Low inspiratory flowMDI with spacer is required when the member has inadequate inspiratory flow that prevents effective use of dry-powder or other inhalers.

Cognitive statusMDI with spacer is required when the member’s cognitive status prevents correct use of alternative inhaler devices.

OpenPayer

Fluticasone propionate HFA prior authorization for members ≥12 years

Coverage and Medical Necessity Criteria

Coding and Age Threshold

Provider Requirements and Prior Authorization Procedures

Background

Definitions and Related Terms