Nasal Allergy Inhalers

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
47335077991 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) N Y N Age Restriction
59651021430 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) N Y N Age Restriction
60505083305 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) N Y N Age Restriction
65162067684 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) N Y N Age Restriction
67877047750 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) N Y N Age Restriction
72603061101 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) N Y N Age Restriction
00378345823 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y N Age Restriction
00480215757 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y N Age Restriction
45802006601 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y N Age Restriction
60505095303 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y N Age Restriction
00037024523 DYMISTA azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y N Age Restriction
59310040606 QNASL CHILDREN beclomethasone dipropionate HFA AER AD 40 mcg/actuation N Y N Age Restriction
59310041012 QNASL beclomethasone dipropionate HFA AER AD 80 mcg/actuation N Y N Age Restriction
00536111248 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation N Y N Age Restriction
00536145684 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation N Y N Age Restriction
46122038976 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation N Y N Age Restriction
60505612902 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation N Y N Age Restriction
70515073760 ZETONNA ciclesonide HFA AER AD 37 mcg/actuation N Y N Age Restriction
70515070101 OMNARIS ciclesonide SPRAY/PUMP 50 mcg N Y N Age Restriction
24208034425 FLUNISOLIDE flunisolide SPRAY 25 mcg (0.025 %) N Y N Age Restriction
50742031725 FLUNISOLIDE flunisolide SPRAY 25 mcg (0.025 %) N Y N Age Restriction
59310003825 NASALIDE flunisolide SPRAY 25 mcg (0.025 %) N Y N Age Restriction
71143037501 XHANCE fluticasone propionate AER BR.ACT 93 mcg/actuation N Y N Age Restriction
71143037599 XHANCE fluticasone propionate AER BR.ACT 93 mcg/actuation N Y N Age Restriction
00113002808 24 HOUR ALLERGY fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
00113002809 24 HOUR ALLERGY fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
70000011001 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
70677102101 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
70677102102 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
83324029401 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
00054327099 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y N Age Restriction
00536118313 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
00536118321 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
00536118365 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
00536118399 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
46122068429 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
46122068435 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
60505082901 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y N Age Restriction
60505620503 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
62135081061 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y N Age Restriction
70000070301 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation N Y N Age Restriction
72888014135 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y N Age Restriction
00054004544 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) N Y N Age Restriction
16714052601 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) N Y N Age Restriction
24208039830 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) N Y N Age Restriction
60505082601 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) N Y N Age Restriction
69238201603 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) N Y N Age Restriction
70748033601 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) N Y N Age Restriction
72888014938 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) N Y N Age Restriction
00054004641 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) N Y N Age Restriction
16714052701 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) N Y N Age Restriction
24208039915 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) N Y N Age Restriction
60505082701 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) N Y N Age Restriction
69238201702 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) N Y N Age Restriction
70748033701 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) N Y N Age Restriction
72888014837 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) N Y N Age Restriction
70000063502 ALLERGY NASAL mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
00536138130 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
00536138170 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
59651040217 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
60505083001 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
65162089129 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
00113172001 NASONEX 24HR ALLERGY mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
00113172002 NASONEX 24HR ALLERGY mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
00113172011 NASONEX 24HR ALLERGY mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y N Age Restriction
45802010401 OLOPATADINE HCL olopatadine HCl SPRAY/PUMP 0.6 % N Y N Age Restriction
60505084505 OLOPATADINE HCL olopatadine HCl SPRAY/PUMP 0.6 % N Y N Age Restriction
65162089023 OLOPATADINE HCL olopatadine HCl SPRAY/PUMP 0.6 % N Y N Age Restriction
59467070027 RYALTRIS olopatadine HCl/mometasone SPRAY/PUMP 665 mcg-25 mcg/spray N Y N Age Restriction
46122038576 24 HOUR NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg N Y N Age Restriction
70677102301 24 HOUR NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg N Y N Age Restriction
00113044301 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg N Y N Age Restriction
45802010901 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg N Y N Age Restriction
60505627507 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg N Y N Age Restriction
70000070201 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg N Y N Age Restriction
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