Pharmacy Prior Authorization Criteria

Nasal Steroids

Indications for Prior Authorization

Xhance (fluticasone propionate)

• For diagnosis of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)
  Indicated for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) in adults.

• For diagnosis of Chronic Rhinosinusitis without Nasal Polyps (CRSsNP)
  Indicated for the treatment of chronic rhinosinusitis without nasal polyps (CRSsNP) in adults.

Criteria

Xhance

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to one of the following:
• generic mometasone nasal spray
• generic flunisolide nasal spray

P & T Revisions

2024-08-26, 2024-08-19, 2024-04-26, 2023-08-21, 2023-01-05, 2022-09-28, 2022-08-22, 2021-07-28, 2020-08-27

References

1. Xhance Prescribing Information. OptiNose US, Inc. Yardley, PA. March 2024.

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Revision History

• 2024-08-26: update guideline
• 2024-08-19: 2024 annual review: no criteria changes.
• 2024-04-26: Update guideline
• 2023-08-21: Annual review - no changes to criteria.
• 2023-01-05: update guideline
• 2022-09-28: update guideline
• 2022-08-22: Annual review: added criterion "Requested drug is being used for a Food and Drug Administration (FDA)-approved indication".
• 2021-07-28: Updated criteria, background, and references.
• 2020-08-27: Annual Review: added minimum day supply for T/F/I

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