ModifiedPremera BluecrossPolicy 5.01.660

Inhaled Corticosteroids

Pharmacy policy governing medical necessity coverage and quantity limits for specified inhaled corticosteroid products for treatment of asthma. Applies to inhaled corticosteroids managed through the pharmacy benefit; documents initial and re-authorization lengths and documentation requirements.

Policy Summary

PayerPremera Bluecross

PolicyInhaled Corticosteroids

Policy CodePolicy 5.01.660

Change TypeNew policy; revised coverage criteria; added quantity limits

Effective DateApr 1, 2026

Next Review Date

Key ActionSubmit office visit notes documenting diagnosis, relevant history, physical evaluation and medication history to demonstrate that medical necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

Moved coverage criteria for inhaled corticosteroids from policy 5.01.605 to new policy 5.01.660.

Updated coverage criteria to include Fluticasone Ellipta as a qualifying product and removed Fluticasone Propionate Diskus as a qualifying product.

Added quantity limits for multiple listed inhaled corticosteroid products.

12Listed Products / Formulations

12Max Authorization (months)

5.01.660Policy Number

Coverage Summary & Indications

Medical Necessity - Covered Indications

Inhaled corticosteroids listed may be considered medically necessary for treatment of asthma when:

ANY of the following

ALL of the following
- Arnuity Ellipta (fluticasone furoate) / Fluticasone Furoate Ellipta
- Fluticasone Propionate HFA
- QVAR Redihaler (beclomethasone)
Is pregnant and is already being treated with the medication

Investigational / Not Covered Uses

Use of the drugs for conditions not listed in this policy are considered investigational.

Any indication not explicitly listed in this policy

Length of Approval - Authorization limits

Authorization limits

ALL of the following

Initial authorization: may be approved up to 12 months for non-formulary exception reviews and all other reviews
Re-authorization: may be approved up to 12 months if drug-specific coverage criteria are met and chart notes demonstrate continued positive clinical response to therapy

Applicable Products / Codes

Listed inhaled corticosteroid products (subject to coverage criteria and quantity limits)mixedCovered

Alvesco	ciclesonide inhaler (80 mcg per actuation; 160 mcg per actuation)
Arnuity Ellipta	fluticasone furoate inhaler (50, 100, 200 mcg per actuation)
Asmanex HFA	mometasone HFA (50, 100, 200 mcg per actuation)
Asmanex Twisthaler	mometasone Twisthaler (110, 220 mcg per actuation)
Pulmicort Flexhaler	budesonide inhaler (90, 180 mcg per actuation)
Pulmicort Respules	budesonide inhalation suspension (0.25 mg/2 mL, 0.5 mg/2 mL, 1 mg/2 mL)
Budesonide inhalation suspension	ampules (0.25 mg/2 mL, 0.5 mg/2 mL, 1 mg/2 mL)
Fluticasone Furoate Ellipta	fluticasone furoate inhaler (50, 100, 200 mcg per actuation)
Fluticasone Propionate Diskus	fluticasone propionate Diskus (50, 100, 250 mcg per actuation)
Fluticasone Propionate HFA	fluticasone propionate HFA (44, 110, 220 mcg per actuation)

1–10 of 11

1/2

Investigational / Not-covered indicationsmixedExperimental

OTHER

Any drugs/conditions not listed in this policy

Prior Authorization, Documentation & Benefit Rules

Prior Authorization

Prior authorization / duration

Non-formulary exception reviews and all other reviews may be approved for up to 12 months for initial authorization; re-authorization may be approved up to 12 months if drug-specific coverage criteria are met and chart notes demonstrate continued positive clinical response to therapy.

Documentation Required

Medical record documentation required

Submit office visit notes documenting the diagnosis, relevant history, physical evaluation and medication history to demonstrate that the medical necessity criteria are met.

Billing Rule

Benefit application

The drugs in this policy are inhaled medications and are managed through the pharmacy benefit.

Clinical Background & Evidence

Inhaled corticosteroids (ICS) reduce airway inflammation and are a core long-term controller therapy for asthma, delivered by inhaler to target the lungs and reduce systemic steroid exposure. They are generally well tolerated with mostly local adverse effects (dysphonia, oropharyngeal candidiasis, cough, throat irritation) and, at high doses, systemic risks (HPA-axis suppression, osteoporosis, skin thinning, bruising, cataracts, glaucoma, and growth suppression in children).

Most handheld ICS devices are labeled for use in young children (typically as young as 4–6 years), but Alvesco (ciclesonide) is approved only for patients aged ≥12 years per product prescribing information. Device selection (e.g., nebulized suspensions vs. dry powder inhalers) may be influenced by inspiratory flow and age.

This policy references the GINA 2024 guidance and experts’ systematic reviews (evidence summarized through May 2024) and the individual product prescribing information for age indications, dosing, and safety details when applying coverage criteria and quantity limits.

ICS: Inhaled corticosteroids

Guideline: GINA 2024 report and experts' systematic reviews

Comparability: ICS are clinically comparable when potency-adjusted dosing is used

Authorization Lengths & Quantity Limits

Product-specific quantity limits (30-day unless otherwise noted):

• Alvesco (ciclesonide): 80 mcg — 1 inhaler; 160 mcg — 2 inhalers.

• Arnuity Ellipta (fluticasone furoate): 50, 100, 200 mcg — 1 inhaler each.

• Asmanex HFA (mometasone): 50, 100, 200 mcg — 1 inhaler each.

• Asmanex Twisthaler (mometasone): 110, 220 mcg — 1 inhaler each.

• Budesonide inhalation suspension / Pulmicort Respules: 0.25 mg/2 mL — 120 ampules; 0.5 mg/2 mL — 120 ampules; 1 mg/2 mL — 60 ampules.

• Pulmicort Flexhaler (budesonide): 90 mcg — 1 inhaler; 180 mcg — 2 inhalers.

• Fluticasone Furoate / Fluticasone Furoate Ellipta: 50, 100, 200 mcg — 1 inhaler each.

• Fluticasone Propionate Diskus: 50 mcg — 1 inhaler; 100 mcg — 1 inhaler; 250 mcg — 4 inhalers.

• Fluticasone Propionate HFA: 44 mcg — 1 inhaler; 110 mcg — 1 inhaler; 220 mcg — 2 inhalers.

Policy Revision History

01/01/26policy_created

New policy created (approved Dec 9, 2025). Moved coverage criteria for inhaled corticosteroids from policy 5.01.605 to new policy 5.01.660.

01/01/26coverage_updated