XHANCE (fluticasone proprionate)

XHANCE (fluticasone proprionate)

SELF ADMINISTRATION - NASAL SPRAY

Indications for Prior Authorization:

• The treatment of nasal polyps in patients 18 years of age or older.

Patients must meet the following criteria for the indication(s) above:

• Patient is 18 years of age or older, AND
• Chart note documentation required documenting diagnosis of nasal polyps, AND
• Patient has tried and failed mometasone nasal spray.

Dosing:

• Up to 2 sprays in each nostril twice daily (total daily dose 744 mcg).
  • One unit provides 120 metered sprays.

Approval:

• 1 year