CurrentUnitedHealthcarePolicy N/A

Fluticasone propionate HFA (Non-Formulary) coverage rules

Defines UnitedHealthcare Pharmacy coverage and authorization requirements for fluticasone propionate HFA for asthma and eosinophilic esophagitis; applies to members whose plans follow UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Policy Summary

PayerUnitedHealthcare

PolicyFluticasone propionate HFA (Non-Formulary) coverage rules

Policy CodePolicy N/A

Change TypeAdded clinical indication and annual review

Effective DateJun 1, 2025

Next Review DateMar 1, 2025

Key ActionObtain prior authorization for fluticasone HFA unless the claim auto-processes (e.g., patients <6 years); document diagnosis and prior failure/intolerance to required agents or need for an MDI with spacer.

SourceLink

POLICY UPDATE CHANGES

Added eosinophilic esophagitis to criteria.

Program listed as Non-Formulary with P&T approval dates and effective date.

Annual review and updated references.

Non-FormularyProgram status

12 monthsAuth duration

6/1/2025Effective

12/2023,3/2024,3/2025P&T dates

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Coverage Criteria

COVERAGE CRITERIA — Asthma

Covered when ALL of the following are met for asthma

Asthma coverage

Requirement A: History of failure, contraindication, or intolerance to both Arnuity Ellipta and QVAR RediHaler
If selecting failure to both products, document prior use or intolerance
Requirement B: Patient requires a metered dose inhaler used with a spacer device due to physical dexterity limitations, inadequate inspiratory flow, or cognitive status
Approval via this pathway supports use when MDI with spacer is clinically necessary

Authorization will be issued for 12 months when criteria are met

COVERAGE CRITERIA — Eosinophilic Esophagitis

Covered when ALL of the following are met for eosinophilic esophagitis

Eosinophilic esophagitis coverage: Member has a diagnosis of eosinophilic esophagitis

Guidelines recommend oral administration of inhalational corticosteroids (e.g., fluticasone) as first-line therapy

Authorization will be issued for 12 months when criteria are met

UnitedHealthcare considers fluticasone propionate HFA to be typically excluded from coverage unless the specific coverage criteria for an approved indication are met. Approval is only granted when the member satisfies the plan’s documented clinical criteria for an indicated diagnosis (see asthma and eosinophilic esophagitis criteria).

Use of fluticasone propionate HFA is not covered / typically excluded when the member does not meet the documented criteria for either asthma or eosinophilic esophagitis. Requests lacking an accepted diagnosis and supporting documentation consistent with the policy criteria may be denied as not medically necessary.

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required when fluticasone propionate HFA is requested for asthma or eosinophilic esophagitis unless an automatic approval process applies.

Affected diagnoses: asthma (ICD-10 codes per claim) and eosinophilic esophagitis

Documentation Required

Asthma — Approval Criteria

For asthma, approval requires documentation of both: a diagnosis of asthma and EITHER 1) history of failure, contraindication, or intolerance to BOTH Arnuity Ellipta and QVAR RediHaler OR 2) documented need for a metered‑dose inhaler used with a spacer due to impaired physical dexterity, inadequate inspiratory flow, or cognitive impairment. Authorizations are issued for 12 months when criteria are met.

Step-failure requirement: Arnuity Ellipta and QVAR RediHaler
Spacer-use requirement: physical dexterity, inspiratory flow, or cognitive status

Initial Therapy Criteria

Initial therapy criteria

Initial authorization rules

Initial asthma: Diagnosis of asthma AND (failure, intolerance, or contraindication to both Arnuity Ellipta and QVAR RediHaler) OR (requires MDI with spacer due to physical dexterity limitations, inadequate inspiratory flow, or cognitive status)

Authorization issued for 12 months if criteria met; document prior use or intolerance for failure pathway

Initial eosinophilic esophagitis: Diagnosis of eosinophilic esophagitis

Authorization issued for 12 months

Continuation / Re-authorization Criteria

Re-authorization duration

Re-authorization

Re-authorization: Continued coverage may be authorized for 12 months when initial criteria continue to be met or when approved via claim/medication history processes

UnitedHealthcare may also approve renewals based on prior claim history or diagnosis codes

Step Therapy / Failure Pathway

Step	Requirement	Coverage decision
Failure pathway
Documented history of failure, contraindication, or intolerance to BOTH Arnuity Ellipta and QVAR RediHaler
Approve via failure pathway

Background

Fluticasone propionate HFA is an inhaled corticosteroid indicated for the maintenance treatment of asthma in adults and pediatric patients. It is also used as a topical (oral) inhalational corticosteroid option recommended by specialty guidance as first-line therapy for eosinophilic esophagitis. Spacers are recommended for certain patients (for example, young children or those with dexterity or inspiratory limitations) to optimize delivery; when criteria are met, authorization is issued for 12 months.

Definitions

Spacer device — definition and recommended use

DefinitionSpacer device: an add-on device used with a metered-dose inhaler to improve drug delivery to the airways.

Recommended use for children <3 yearsUse spacer with face mask for children under 3 years of age.

Recommended use for children 3–5 yearsUse spacer with mouthpiece for children ages 3–5 years.

Use in elderly patientsSpacers may be essential for some elderly patients who are unable to correctly use inhalation devices.

PurposeImproves delivery of medication from a metered‑dose inhaler by reducing oropharyngeal deposition and coordinating actuation with inhalation.