Subject: Xhance PA with Limit 4364-C P02-2026

Drug

XHANCE  (fluticasone propionate nasal spray)

Policy:

Indications

FDA-approved Indications

Chronic Rhinosinusitis with Nasal Polyps

XHANCE is indicated for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) in adults.

Chronic Rhinosinusitis without Nasal Polyps

XHANCE is indicated for the treatment of chronic rhinosinusitis without nasal polyps (CRSsNP) in adults.

Coverage Criteria

Chronic Rhinosinusitis with or without Nasal Polyps

Authorization may be granted when the requested drug is being prescribed for the treatment of chronic rhinosinusitis with or without nasal polyps in an adult when ONE of the following criteria is met:

·        The patient has experienced an inadequate treatment response to an alternative intranasal corticosteroid therapy.

·        The patient has experienced an intolerance to an alternative intranasal corticosteroid therapy.

·        The patient is not a candidate for a trial with an alternative intranasal corticosteroid therapy.

Continuation of Therapy

Chronic Rhinosinusitis with or without Nasal Polyps

Authorization may be granted when the requested drug is being prescribed for the treatment of chronic rhinosinusitis with or without nasal polyps in an adult when the following criteria is met:

·        The patient has achieved or maintained a positive clinical response to the requested drug (i.e., improvement in nasal congestion, mucopurulent drainage, facial pain/pressure/fullness, sense of smell, improvement in polyp grade).

Quantity Limits Apply

2 packages of 16 mL each (32 mL) / 25 days or 6 packages of 16 mL each (96 mL) / 75 days.

The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.

Duration of Approval (DOA):

·        4364-C: DOA: 12 months

Place of Service:

Outpatient

The above policy is based on the following references:

1.      Xhance [package insert]. Yardley, PA: OptiNose US, Inc; March 2024.

2.     Mometasone Furoate [package insert]. Weston, FL: Apotex Corp.; April 2025

3.     Lexicomp Online, Lexi-Drugs. Waltham, MA: UpToDate, Inc.; 2026. https://online.lexi.com. Accessed January 3, 2026.

4.     Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 01/03/2026).

5.     Payne SC, McKenna M, Buckley J, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2025,173(1 Suppl):S1-S56.

Copyright 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.

August 20, 2026