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
59651021430 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) Y Y  
60505083305 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) Y Y  
65162067684 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) Y Y  
67877047750 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) Y Y  
72603061101 AZELASTINE HCL azelastine HCl SPRAY/PUMP 137 mcg (0.1 %) Y Y  
00280006501 ASTEPRO ALLERGY azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00280006502 ASTEPRO ALLERGY azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00280006504 ASTEPRO ALLERGY azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00280006510 ASTEPRO ALLERGY azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00363065301 AZELASTINE HCL azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00363065302 AZELASTINE HCL azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00363065303 AZELASTINE HCL azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00363065304 AZELASTINE HCL azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00280006601 CHILDREN'S ASTEPRO ALLERGY azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00280006602 CHILDREN'S ASTEPRO ALLERGY azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00280006603 CHILDREN'S ASTEPRO ALLERGY azelastine HCl SPRAY/PUMP 205.5 mcg (0.15 %) Y N  
00378345823 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y Age Restriction
00480215757 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y Age Restriction
45802006601 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y Age Restriction
60505095303 AZELASTINE-FLUTICASONE azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y Age Restriction
00037024523 DYMISTA azelastine/fluticasone SPRAY/PUMP 137 mcg-50 mcg/spray N Y Age Restriction
59310040606 QNASL CHILDREN beclomethasone dipropionate HFA AER AD 40 mcg/actuation N Y Age Restriction
59310041012 QNASL beclomethasone dipropionate HFA AER AD 80 mcg/actuation N Y Age Restriction
11822061559 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y N  
49035070301 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y N  
50428052804 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y N  
69842000101 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y N  
87701042901 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y N  
00536145684 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y Y  
46122038976 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y Y  
60505612902 BUDESONIDE budesonide SPRAY/PUMP 32 mcg/actuation Y Y  
70515073760 ZETONNA ciclesonide HFA AER AD 37 mcg/actuation N Y Age Restriction
70515070101 OMNARIS ciclesonide SPRAY/PUMP 50 mcg N Y Age Restriction
50742031725 FLUNISOLIDE flunisolide SPRAY 25 mcg (0.025 %) N Y Age Restriction
59310003825 NASALIDE flunisolide SPRAY 25 mcg (0.025 %) N Y Age Restriction
71143037501 XHANCE fluticasone propionate AER BR.ACT 93 mcg/actuation N Y Age Restriction
71143037599 XHANCE fluticasone propionate AER BR.ACT 93 mcg/actuation N Y Age Restriction
00363002401 24 HOUR ALLERGY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00363002402 24 HOUR ALLERGY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
11917018202 24 HOUR ALLERGY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00113002808 24 HOUR ALLERGY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
00113002809 24 HOUR ALLERGY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
30142030101 24 HOUR ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
30142030102 24 HOUR ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
30142030103 24 HOUR ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
63981000101 ALLER-FLO fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
63981000105 ALLER-FLO fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
63981000113 ALLER-FLO fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
96619010284 ALLER-FLO fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
11673010301 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
11673010302 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
11673010303 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
35515099529 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
49035020001 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
81131012979 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
96295012745 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
70000011001 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
70677102101 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
70677102102 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
83324029401 ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
72657016672 CHILD FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135058201 CHILDREN'S FLONASE ALLERGY RLF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135058204 CHILDREN'S FLONASE ALLERGY RLF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020125 CHILDREN'S FLONASE ALLERGY RLF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020135 CHILDREN'S FLONASE ALLERGY RLF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00280007210 CLARISPRAY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00280007215 CLARISPRAY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
41100081144 CLARISPRAY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
41100081165 CLARISPRAY fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135057602 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135057603 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135057614 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135057615 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135057616 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00135057617 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020010 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020020 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020050 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020265 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020266 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100020334 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100022889 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100022957 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
53100029616 FLONASE ALLERGY RELIEF fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
11917018251 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
11917018705 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
36800002801 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
36800022201 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
36800057201 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
41163002309 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
50090682300 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
50428034380 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
50428050841 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
58602001742 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
69842000003 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
69842090001 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
69842090008 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
69842090009 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
69842090010 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
69842090011 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
72657015912 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
72657015914 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
72657015928 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
72657015972 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
87701042742 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
87701042743 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
87701042897 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y N  
00054327099 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
00536118313 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
00536118321 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
00536118365 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
00536118399 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
46122068429 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
46122068435 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
60505082901 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
60505620503 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
62135081061 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
68462091820 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
70000070301 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
71085009016 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
71085009032 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
72888014135 FLUTICASONE PROPIONATE fluticasone propionate SPRAY SUSP 50 mcg/actuation Y Y  
00054004544 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) Y Y  
16714052601 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) Y Y  
60505082601 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) Y Y  
69238201603 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) Y Y  
70748033601 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) Y Y  
72888014938 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 21 mcg (0.03 %) Y Y  
00054004641 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) Y Y  
16714052701 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) Y Y  
60505082701 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) Y Y  
69238201702 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) Y Y  
70748033701 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) Y Y  
72888014837 IPRATROPIUM BROMIDE ipratropium bromide SPRAY 42 mcg (0.06 %) Y Y  
70000063501 ALLERGY NASAL mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
70000063502 ALLERGY NASAL mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
00536138130 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
00536138170 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
59651040217 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
60505083001 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
65162089129 MOMETASONE FUROATE mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
00113172001 NASONEX 24HR ALLERGY mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
00113172002 NASONEX 24HR ALLERGY mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
00113172011 NASONEX 24HR ALLERGY mometasone furoate SPRAY/PUMP 50 mcg/actuation N Y Age Restriction
45802010401 OLOPATADINE HCL olopatadine HCl SPRAY/PUMP 0.6 % N Y Age Restriction
60505084505 OLOPATADINE HCL olopatadine HCl SPRAY/PUMP 0.6 % N Y Age Restriction
65162089023 OLOPATADINE HCL olopatadine HCl SPRAY/PUMP 0.6 % N Y Age Restriction
59467070027 RYALTRIS olopatadine HCl/mometasone SPRAY/PUMP 665 mcg-25 mcg/spray N Y Age Restriction
68462065927 RYALTRIS olopatadine HCl/mometasone SPRAY/PUMP 665 mcg-25 mcg/spray N Y Age Restriction
00363081101 24 HOUR NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
87701042896 24 HOUR NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
46122038576 24 HOUR NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y Y  
70677102301 24 HOUR NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y Y  
63981044301 ALLER-CORT triamcinolone acetonide SPRAY 55 mcg Y N  
63981044304 ALLER-CORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167058002 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167058003 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167058005 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167580001 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167580002 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167580003 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167580005 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
41167580007 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
50090144400 NASACORT triamcinolone acetonide SPRAY 55 mcg Y N  
11822068596 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
30142044301 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
30142044303 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
41163044301 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
41260038140 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
49035044301 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
50428053389 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
59779074601 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
81131012373 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
96295013053 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y N  
00113044301 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y Y  
00536145769 NASAL ALLERGY triamcinolone acetonide SPRAY 55 mcg Y Y  
72162228902 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg Y N  
45802010901 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg Y Y  
60505627507 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg Y Y  
70000070201 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg Y Y  
70000074201 TRIAMCINOLONE ACETONIDE triamcinolone acetonide SPRAY 55 mcg Y Y  
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