Nasal Allergy Inhalers

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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 HFA AER AD N Age Restriction  
beclomethasone dipropionate QNASL CHILDREN 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 NASAL ALLERGY CONTROL SPRAY/PUMP N Age Restriction  
cromolyn sodium CROMOLYN SODIUM 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  
mometasone furoate ALLERGY NASAL 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 NASAL ALLERGY SPRAY N Age Restriction  
triamcinolone acetonide TRIAMCINOLONE ACETONIDE SPRAY N Age Restriction  
triamcinolone acetonide 24 HOUR NASAL ALLERGY SPRAY N Age Restriction