Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsPremera Inhaled Corticosteroid Prior Auth | OpenPa…
    Ask Trek AI about this page
    CurrentPremera Blue Cross of WashingtonPolicy 5.01.660

    Inhaled Corticosteroids

    Customize your policy alerts

    Sign up for premerabluecrossofwashington Policy 5.01.660 alerts

    Get alerted when Policy 5.01.660 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs pharmacy-benefit coverage and prior authorization for selected inhaled corticosteroids used to treat asthma. It applies to providers evaluating medical necessity and does not apply to Medicare Advantage.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyInhaled Corticosteroids
    Policy CodePolicy 5.01.660
    Change TypeAnnual review and revision
    Effective DateNovember 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with records showing medical necessity and continued positive clinical response when requesting renewal.
    SourceLink
    POLICY UPDATE CHANGES

    Policy created by moving inhaled corticosteroid coverage criteria from policy 5.01.605.

    Qualifying-product criteria were updated to include Fluticasone Ellipta and remove Fluticasone Propionate Diskus.

    Quantity limits were added during the April 1, 2026 interim review.

    References to non-formulary exception reviews and quantity limits were removed during the November 1, 2026 annual review.

    5Products with medical-necessity criteria
    2 of 3Qualifying products required
    12 months

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Maximum initial authorization
    12 monthsMaximum reauthorization
    PharmacyBenefit

    Medical Necessity and Coverage Criteria

    Initial medical necessity criteria

    The following inhaled corticosteroids may be considered medically necessary for the treatment of asthma when the requirement below is met:

    Medical necessity

    • The individual has asthma.

    • 2 of 3 qualifying products

      • The individual has had an inadequate response or intolerance to Arnuity Ellipta (fluticasone furoate)/Fluticasone Furoate Ellipta.
      • The individual has had an inadequate response or intolerance to Fluticasone Propionate HFA.
      • The individual has had an inadequate response or intolerance to QVAR Redihaler (beclomethasone).

    Reauthorization criteria

    Reauthorization may be approved when all of the following are met:

    Reauthorization

    • The drug-specific coverage criteria are met.
    • The individual continues to show a positive clinical response to therapy.Up to 12 months

    Conditions not listed in this policy are excluded from covered use. Use of a drug listed in this policy for an unlisted condition is considered investigational and may be denied.

    Authorization and Documentation Requirements

    Prior Authorization

    Initial and Renewal Authorization

    Prior authorization is required for the drugs listed in this policy. Initial authorization and reauthorization may each be approved for up to 12 months when the applicable criteria are met.

    • Initial authorization: up to 12 months.
    • Reauthorization: up to 12 months when drug-specific coverage criteria are met and there is evidence of continued positive clinical response.
    Step Therapy

    Failure or Intolerance of Two Preferred Products

    Before coverage of Alvesco (ciclesonide), Asmanex HFA (mometasone), Asmanex Twisthaler (mometasone), or Pulmicort Flexhaler (budesonide) for asthma, the individual must have had an inadequate response or intolerance to two preferred products.

    • Required qualifying products: Arnuity Ellipta (fluticasone furoate) / fluticasone furoate Ellipta; Fluticasone Propionate HFA; and QVAR Redihaler (beclomethasone).
    • Document inadequate response or intolerance to two of the three listed preferred products.

    Asthma and Treatment Context

    Asthma is a chronic inflammatory respiratory disease characterized by airway hyperresponsiveness and inflammation. Typical symptoms include wheezing, shortness of breath, cough, and chest tightness. Exacerbations may require intensified therapy or hospitalization. Inhaled corticosteroids reduce airway inflammation and are an important long-term treatment for asthma.

    Key Terms

    Inhaled corticosteroid
    DefinitionA medication class that reduces inflammation in the airways.
    Asthma-treatment roleInhaled corticosteroids help control asthma symptoms and prevent flare-ups.
    Investigational use
    DefinitionUse of a drug for a condition not listed in this policy.
    Coverage statusUse for an unlisted condition is considered investigational.

    Initial Therapy and Step Therapy

    Initial therapy and step therapy

    The following drugs may be considered medically necessary for treatment of asthma when the step-therapy requirements are met:

    Initial treatment requirements

    • The individual has asthma.

    • 2 of 3 qualifying products

      • The individual has had an inadequate response or intolerance to Arnuity Ellipta (fluticasone furoate)/Fluticasone Furoate Ellipta.
      • The individual has had an inadequate response or intolerance to Fluticasone Propionate HFA.
      • The individual has had an inadequate response or intolerance to QVAR Redihaler (beclomethasone).

    Continuation and Reauthorization Therapy

    Continuation therapy

    Reauthorization criteria:

    • The drug-specific coverage criteria are met.
    • The individual continues to show a positive clinical response to therapy.Authorization up to 12 months

    Qualifying Product Requirements

    RequirementQualifying products
    Document an inadequate response or intolerance to 2 of 3 productsArnuity Ellipta (fluticasone furoate)/Fluticasone Furoate Ellipta; Fluticasone Propionate HFA; or QVAR Redihaler (beclomethasone)
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyInhaled Corticosteroids
    Policy CodePolicy 5.01.660
    Change TypeAnnual review and revision
    Effective DateNovember 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with records showing medical necessity and continued positive clinical response when requesting renewal.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaAuthorization and Documentation RequirementsAsthma and Treatment ContextKey TermsInitial Therapy and Step TherapyContinuation and Reauthorization TherapyQualifying Product Requirements
    Documentation Required

    Required Clinical Records

    Submit medical records demonstrating that the medical-necessity criteria are met for the requested medication and condition.

    • Office visit notes documenting the diagnosis.
    • Relevant medical history and physical evaluation.
    • Medication history, including the required prior therapy and the individual's response or intolerance.
    Denial Risk

    Unlisted Condition

    Use of the drugs listed in this policy for conditions not addressed by the policy is considered investigational and may be denied. The medications are also subject to the product's U.S. Food and Drug Administration (FDA) dosage and administration prescribing information unless otherwise noted in the medical-necessity criteria.

    • Submit the diagnosis and requested use for an indication addressed by the policy.
    • Conditions not listed in the policy are considered investigational.
    Denial Risk

    Insufficient Prior Therapy

    Coverage may be denied when the records do not document an inadequate response or intolerance to two of the required qualifying preferred products.

    • Document the specific preferred products tried.
    • Document the inadequate response or intolerance for each of two qualifying products.
    Documentation Required

    Document Ongoing Positive Response

    At reauthorization, provide evidence that the individual continues to show a positive clinical response to therapy. Reauthorization may be approved for up to 12 months when the drug-specific coverage criteria and continued-response requirement are met.

    • Include current clinical documentation demonstrating ongoing benefit from treatment.
    • Absence of documented continued positive clinical response may result in denial of reauthorization.