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Nasal Inhalers Quantity Limit Program Summary

Policy Number: PH-1190

This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace.

POLICY REVIEW CYCLE                                                                                                                                                                           

Effective Date

Date of Origin 

04-01-2024            

FDA APPROVED INDICATIONS AND DOSAGE

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

                                                                                                                                                                           

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Azelastine HCl Nasal Spray 0.1% (137 MCG/SPRAY)

0.1 % ; 137 MCG/SPRAY

2

Bottles

30

DAYS

Flunisolide Nasal Soln 25 MCG/ACT (0.025%)

0.025 %

3

Bottles

30

DAYS

Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY)

0.03 %

2

Bottles

30

DAYS

Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY)

0.06 %

3

Bottles

30

DAYS

Allergy nasal spray 24 ho ; Allergy relief ; Clarispray ; Cvs fluticasone propionat ; Cvs fluticasone propriona ; Eq allergy relief ; Eql fluticasone propionat ; Flonase allergy relief ; Flonase allergy relief ch ; Ft allergy relief 24 hr ; Gnp fluticasone propionat ; Goodsense 24-hour allergy ; Hm allergy relief nasal s ; Kls aller-flo ; Qc allergy relief ; Sm allergy relief nasal s

fluticasone propionate nasal susp

50 MCG/ACT

1

Bottle

30

DAYS

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

2

Bottles

30

DAYS

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

2

Bottles

30

DAYS

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

2

Bottles

30

DAYS

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

2

Bottles

30

DAYS

Beconase aq

Beclomethasone Dipropionate Monohyd Nasal Susp 42 MCG/SPRAY

42 MCG/SPRAY

2

Inhalers

30

DAYS

Dymista

Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT

137-50 MCG/ACT

1

Bottle

30

DAYS

Dymista

Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT

137-50 MCG/ACT

1

Bottle

30

DAYS

Nasonex 24hr

Mometasone Furoate Nasal Susp 50 MCG/ACT

50 MCG/ACT

2

Bottles

30

DAYS

Nasonex 24hr

Mometasone Furoate Nasal Susp 50 MCG/ACT

50 MCG/ACT

2

Bottles

30

DAYS

Omnaris

Ciclesonide Nasal Susp 50 MCG/ACT

50 MCG/ACT

1

Inhaler

30

DAYS

Patanase

Olopatadine HCl Nasal Soln 0.6%

0.6 %

1

Bottle

30

DAYS

Patanase

Olopatadine HCl Nasal Soln 0.6%

0.6 %

1

Bottle

30

DAYS

Patanase

Olopatadine HCl Nasal Soln 0.6%

0.6 %

1

Bottle

30

DAYS

Qnasl

Beclomethasone Dipropionate Nasal Aerosol 80 MCG/ACT

80 MCG/ACT

1

Inhaler

30

DAYS

Qnasl childrens

Beclomethasone Dipropionate Nasal Aerosol 40 MCG/ACT

40 MCG/ACT

1

Inhaler

30

DAYS

Ryaltris

Olopatadine HCl-Mometasone Furoate Nasal Susp

665-25 MCG/ACT

1

Bottle

30

DAYS

Zetonna

Ciclesonide Nasal Aerosol Soln 37 MCG/ACT (50 MCG/Valve)

37 MCG/ACT

1

Inhaler

30

DAYS

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Azelastine HCl Nasal Spray 0.1% (137 MCG/SPRAY)

0.1 % ; 137 MCG/SPRAY

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flunisolide Nasal Soln 25 MCG/ACT (0.025%)

0.025 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY)

0.03 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY)

0.06 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Allergy nasal spray 24 ho ; Allergy relief ; Clarispray ; Cvs fluticasone propionat ; Cvs fluticasone propriona ; Eq allergy relief ; Eql fluticasone propionat ; Flonase allergy relief ; Flonase allergy relief ch ; Ft allergy relief 24 hr ; Gnp fluticasone propionat ; Goodsense 24-hour allergy ; Hm allergy relief nasal s ; Kls aller-flo ; Qc allergy relief ; Sm allergy relief nasal s

fluticasone propionate nasal susp

50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Astepro ; Astepro childrens

Azelastine HCl Nasal Spray 0.15% (205.5 MCG/SPRAY)

0.15 % ; 205.5 MCG/SPRAY

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Beconase aq

Beclomethasone Dipropionate Monohyd Nasal Susp 42 MCG/SPRAY

42 MCG/SPRAY

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Dymista

Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT

137-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Dymista

Azelastine HCl-Fluticasone Prop Nasal Spray 137-50 MCG/ACT

137-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nasonex 24hr

Mometasone Furoate Nasal Susp 50 MCG/ACT

50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nasonex 24hr

Mometasone Furoate Nasal Susp 50 MCG/ACT

50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Omnaris

Ciclesonide Nasal Susp 50 MCG/ACT

50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Patanase

Olopatadine HCl Nasal Soln 0.6%

0.6 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Patanase

Olopatadine HCl Nasal Soln 0.6%

0.6 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Patanase

Olopatadine HCl Nasal Soln 0.6%

0.6 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Qnasl

Beclomethasone Dipropionate Nasal Aerosol 80 MCG/ACT

80 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Qnasl childrens

Beclomethasone Dipropionate Nasal Aerosol 40 MCG/ACT

40 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ryaltris

Olopatadine HCl-Mometasone Furoate Nasal Susp

665-25 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zetonna

Ciclesonide Nasal Aerosol Soln 37 MCG/ACT (50 MCG/Valve)

37 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
    2. BOTH of the following:
      1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication

Length of Approval: up to 12 months

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

 

 

 

Commercial _ PS _ Nasal_Inhalers_QL _ProgSum_ 04-01-2024