Nasal Allergy Inhalers
PDL Reference Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| fluticasone propionate | FLUTICASONE PROPIONATE | SPRAY SUSP | Y | Age Restriction | |
| azelastine HCl | AZELASTINE HCL | SPRAY/PUMP | N | Age Restriction | |
| azelastine/fluticasone | AZELASTINE-FLUTICASONE | SPRAY/PUMP | N | Age Restriction | |
| azelastine/fluticasone | DYMISTA | SPRAY/PUMP | N | Age Restriction | |
| beclomethasone dipropionate | QNASL CHILDREN | HFA AER AD | N | Age Restriction | |
| beclomethasone dipropionate | QNASL | HFA AER AD | N | Age Restriction | |
| beclomethasone dipropionate | BECONASE AQ | SPRAY | N | Age Restriction | |
| budesonide | BUDESONIDE | SPRAY/PUMP | N | Age Restriction | |
| ciclesonide | ZETONNA | HFA AER AD | N | Age Restriction | |
| ciclesonide | OMNARIS | SPRAY/PUMP | N | Age Restriction | |
| cromolyn sodium | CROMOLYN SODIUM | SPRAY/PUMP | N | Age Restriction | |
| cromolyn sodium | NASAL ALLERGY CONTROL | SPRAY/PUMP | N | Age Restriction | |
| flunisolide | NASALIDE | SPRAY | N | Age Restriction | |
| flunisolide | FLUNISOLIDE | SPRAY | N | Age Restriction | |
| fluticasone propionate | XHANCE | AER BR.ACT | N | Age Restriction | |
| fluticasone propionate | FLUTICASONE PROPIONATE | SPRAY SUSP | N | Age Restriction | |
| fluticasone propionate | ALLERGY RELIEF | SPRAY SUSP | N | Age Restriction | |
| fluticasone propionate | 24 HOUR ALLERGY | SPRAY SUSP | N | Age Restriction | |
| ipratropium bromide | IPRATROPIUM BROMIDE | SPRAY | N | Age Restriction | |
| mometasone furoate | NASONEX 24HR ALLERGY | SPRAY/PUMP | N | Age Restriction | |
| mometasone furoate | MOMETASONE FUROATE | SPRAY/PUMP | N | Age Restriction | |
| olopatadine HCl | OLOPATADINE HCL | SPRAY/PUMP | N | Age Restriction | |
| olopatadine HCl/mometasone | RYALTRIS | SPRAY/PUMP | N | Age Restriction | |
| triamcinolone acetonide | 24 HOUR NASAL ALLERGY | SPRAY | N | Age Restriction | |
| triamcinolone acetonide | TRIAMCINOLONE ACETONIDE | SPRAY | N | Age Restriction | |
| triamcinolone acetonide | NASAL ALLERGY | SPRAY | N | Age Restriction |