Subject: Nasal Sprays

Status	Drug	PR-B/D	PR	PR-QL	PR-AL	ST	M EX‡	TOC§
C	flunisolide nasal solution
C	fluticasone propionate nasal spray
C	ipratropium nasal solution
NC	Atrovent®  (ipratropium nasal solution)						X
NC	Beconase AQ®  (beclomethasone)						X
NC	Flonase®  (fluticasone)						X
NC	Nasacort AQ®  (triamcinolone)						X
NC	Nasarel®  (flunisolide)						X
NC	Nasonex®  (mometasone)						X
NC	Rhinocort Aqua®  (budesonide)						X
NC	Veramyst®  (fluticasone furoate)						X

Policy:

1. Medical Exception Criteria

Atrovent, Beconase AQ, Flonase, Nasacort AQ, Nasarel, Nasonex, Rhinocort Aqua and Veramyst are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.*  Therefore, they are excluded from coverage for members enrolled in prescription drug benefits plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Atrovent, Beconase AQ, Flonase, Nasacort AQ, Nasarel, Nasonex, Rhinocort Aqua and Veramyst to be medically necessary for those members who meet ANY of the following criteria:

A documented:

• Contraindication to two preferred nasal sprays for rhinitis OR
• Allergy to two preferred nasal sprays for rhinitis OR
• Intolerance to two preferred nasal sprays for rhinitis OR
• Failure of an adequate trial of two weeks each of two preferred nasal sprays for rhinitis

Place of Service:

Outpatient

The above policy is based on the following references:

1. Nathan RA. Changing strategies in the treatment of allergic rhinitis. Ann Allergy Asthma Immunol. 1996;77:255-9.
2. Spector SL. Overview of comorbid associations of allergic rhinitis. J Allergy Clin Immunol. 1997: 99: s773-80
3. FDA Talk Paper: FDA requires new pediatric labeling for inhaled, intranasal corticosteroids. T98-79; November 9, 1998.
4. Nielsen LP, Mygina N, Dahl R. Intranasal corticosteroids for allergic rhinitis. Drugs. 2001;61:1563-79.
5. Boner AL. Effects of intranasal corticosteroids on the hypothalamic-pituitary-adrenal axis in children. J Allergy Clin Immunol. 2001;108:S32-9.
6. Pedersen S. Assessing the effect of intranasal steroids on growth. J Allergy Clin Immunol. 2001;108:S40-4.
7. Allen DB. Systemic effects of intranasal steroids: an endocrinologist’s perspective. J Allergy Clin Immunol. 2000;106:S179-90.
8. Scadding GK. Corticosteroids in the treatment of pediatric allergic rhinitis. J Allergy Clin Immunol. 2001;108:S59-64.
9. Corren J. Intranasal corticosteroids for allergic rhinitis: how do different agents compare? J Allergy Clin Immunol. 1999;104:S144-9.
10. Dykewicz MS, Fineman S, ed., Skoner DP, Chair. Diagnosis and management of rhinitis: Complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. 1998;81:478-518.
11. Long A, McFadden C, DeVine D, et al. Management of Allergic and Nonallergic Rhinitis; Evidence Report/Technology Assessment No. 54 (prepared by New England Medical Center Evidence-based Practice Center, contract No. 290-97-0019). AHRQ Publication No. 02-E024. Rockville, MD: Agency for Healthcare Research and Quality. May 2002.
12. ICSI Health Care Guideline: Chronic Rhinitis. Rochester, MN: Institute for Clinical Systems Improvement. December 2001; accessed March 7, 2003. http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=158  
13. University of Michigan Health System. Guidelines for Clinical Care: Allergic Rhinitis. Ann Arbor, MI: University of Michigan Health System. July 2002. http://cme.med.umich.edu/iCME/AllergicRhinitis/Default.asp, accessed March 7, 2003.
14. Rosenwasser LJ. Treatment of allergic rhinitis. Am J Med. 2002;113:17S.
15. Trangsrud AJ, Whitaker AL, Small RE. Intranasal corticosteroids for allergic rhinitis. Pharmacotherapy. 2002;22(11):1458-67.
16. Nasacort AQ Product Information. Aventis Pharmaceuticals Inc, Bridgewater, NJ. December 2002.
17. Beconase AQ Product Information. GlaxoSmithKline, Research Triangle Park, NC. December 2002.
18. Rhinocort Aqua Product Information. AstraZeneca LP, Wilmington, DE. October 2001.
19. USPDI Drug Information for the HealthCare Professional (online). Thomson MICROMEDEX, Greenwood Village, Colorado; 2004.
20. McEvoy GK, editor. AHFS Drug Information (online). American Society of Health-Systems Pharmacists, Bethesda, Maryland; 2004.
21. Olin BR, editor. Drugs Facts and Comparisons (electronic online version). St. Louis: J.B. Lippincott Company, 2004.
22. Fick DM, Cooper JW, Wade WE, et al.  Updating the Beers criteria for potentially inappropriate medication use in older adults.  Arch Intern Med. 2003;163:2716-24.
23. Zahn C, Sangl J, Bierman AS, et al.  Potentially inappropriate medication use in the community-dwelling elderly.  JAMA.  2001;286:2823-29.

 

Property of Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

May 10, 2007