RYALTRIS (olopatadine/mometasone furoate)

RYALTRIS (olopatadine/mometasone furoate)

Self-Administration – nasal

Diagnosis considered for coverage:

• Seasonal allergic rhinitis: Indicated for the treatment of symptoms of seasonal allergic rhinitis in adult and pediatric patients 12 years of age and older.

Coverage Criteria:

For diagnosis of seasonal allergic rhinitis:

• Dose does not exceed 2 sprays in each nostril twice daily (2 sprays deliver a total of 1,330 mcg of olopatadine hydrochloride and 50 mcg of mometasone furoate); AND
• Patient is 12 years of age and older; AND
• Diagnosis of seasonal allergic rhinitis; AND
• Trial and failure (of a minimum 30-day supply), intolerance, or contraindication to ONE of the following:
  • Generic mometasone nasal spray
  • Beconase AQ 

Reauthorization Criteria:

For diagnosis of seasonal allergic rhinitis:

• Dose does not exceed 2 sprays in each nostril twice daily (2 sprays deliver a total of 1,330 mcg of olopatadine hydrochloride and 50 mcg of mometasone furoate); AND
• Documentation of positive clinical response to therapy

Coverage Duration: 

• Initial: 1 year
• Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

• Dosage and Administration
  • For nasal use only
  • Ryaltris – recommended dosage is 2 sprays in each nostril twice daily

Policy Updates:

• 3/1/2023 – New policy approved by P&T

References:

• Ryaltris prescribing information. Hikma Specialty USA Inc. Columbus, OH. July 2022.