Fluticasone proprionate (Xhance™)

SELF ADMINISTRATION

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

Dosing:

  • 1 spray in each nostril twice daily (total daily dose 372 mcg)
  • Max: 2 sprays in each nostril twice daily (total daily dose 744 mcg)

Approval:

  • 1 year

Last review date: December 17, 2018