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 but eligible patients will encounter a co-pay at the pharmacy.
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 PA Document  
azelastine HCl AZELASTINE HCL SPRAY/PUMP N PA Document  
azelastine HCl ASTEPRO SPRAY/PUMP N PA Document  
azelastine/fluticasone DYMISTA SPRAY/PUMP N PA Document  
beclomethasone dipropionate QNASL HFA AER AD N PA Document  
beclomethasone dipropionate QNASL CHILDREN HFA AER AD N PA Document  
beclomethasone dipropionate BECONASE AQ SPRAY N PA Document  
budesonide BUDESONIDE SPRAY/PUMP N PA Document  
ciclesonide ZETONNA HFA AER AD N PA Document  
ciclesonide OMNARIS SPRAY/PUMP N PA Document  
cromolyn sodium CROMOLYN SODIUM SPRAY/PUMP N PA Document  
flunisolide FLUNISOLIDE SPRAY N PA Document  
fluticasone furoate CHILDREN'S FLONASE SENSIMIST SPRAY SUSP N PA Document  
fluticasone furoate FLONASE SENSIMIST SPRAY SUSP N PA Document  
fluticasone propionate FLUTICASONE PROPIONATE SPRAY SUSP N PA Document  
fluticasone propionate ALLERGY RELIEF SPRAY SUSP N PA Document  
fluticasone propionate FLONASE ALLERGY RELIEF SPRAY SUSP N PA Document  
fluticasone propionate CHILDREN'S FLONASE ALLERGY RLF SPRAY SUSP N PA Document  
ipratropium bromide IPRATROPIUM BROMIDE SPRAY N PA Document  
mometasone furoate MOMETASONE FUROATE SPRAY/PUMP N PA Document  
mometasone furoate NASONEX SPRAY/PUMP N PA Document  
olopatadine HCl OLOPATADINE HCL SPRAY/PUMP N PA Document  
olopatadine HCl PATANASE SPRAY/PUMP N PA Document  
triamcinolone acetonide 24 HOUR NASAL ALLERGY SPRAY N PA Document  
triamcinolone acetonide TRIAMCINOLONE ACETONIDE SPRAY N PA Document