RYALTRIS (olopatadine/mometasone furoate)

Self-Administration – nasal

Diagnosis considered for coverage:
  • Seasonal allergic rhinitis: Indicated for the treatment of symptoms of seasonal allergic rhinitis in adult and pediatric patients 12 years of age and older.

Coverage Criteria:

For diagnosis of seasonal allergic rhinitis:

  • Dose does not exceed 2 sprays in each nostril twice daily (2 sprays deliver a total of 1,330 mcg of olopatadine hydrochloride and 50 mcg of mometasone furoate); AND
  • Patient is 12 years of age and older; AND
  • Diagnosis of seasonal allergic rhinitis; AND
  • Trial and failure (of a minimum 30-day supply), intolerance, or contraindication to ONE of the following:
    • Generic mometasone nasal spray
    • Beconase AQ 
Reauthorization Criteria:

For diagnosis of seasonal allergic rhinitis:

  • Dose does not exceed 2 sprays in each nostril twice daily (2 sprays deliver a total of 1,330 mcg of olopatadine hydrochloride and 50 mcg of mometasone furoate); AND
  • Documentation of positive clinical response to therapy
Coverage Duration: 
  • Initial: 1 year
  • Reauthorization: 1 year
Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 
  • Dosage and Administration
    • For nasal use only
    • Ryaltris – recommended dosage is 2 sprays in each nostril twice daily
Policy Updates:
  • 3/1/2023 – New policy approved by P&T
References:
  • Ryaltris prescribing information. Hikma Specialty USA Inc. Columbus, OH. July 2022.

Last review date: March 1, 2023

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