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 CHILDREN HFA AER AD N PA Document  
BECLOMETHASONE DIPROPIONATE QNASL 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 FLONASE SENSIMIST SPRAY SUSP N PA Document  
FLUTICASONE PROPIONATE CHILDREN'S FLONASE ALLERGY RLF SPRAY SUSP N PA Document  
FLUTICASONE PROPIONATE FLONASE ALLERGY RELIEF SPRAY SUSP N PA Document  
FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE SPRAY SUSP N PA Document  
FLUTICASONE PROPIONATE ALLERGY RELIEF 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 PATANASE SPRAY/PUMP N PA Document  
OLOPATADINE HCL OLOPATADINE HCL SPRAY/PUMP N PA Document  
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE SPRAY N PA Document