Asset Publisher

ph-1191

print Print

Oral Inhalers Step Therapy with Quantity Limit Program Summary

Policy Number: PH-1191

This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace      

POLICY REVIEW CYCLE

Effective Date

Date of Origin 

04-01-2024            

FDA APPROVED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

ADVAIR DISKUS®

(fluticasone propionate and salmeterol)*

Inhalation powder

Twice-daily treatment of asthma in patients 4 years of age and older. 

Maintenance treatment of airflow obstruction and reducing exacerbations in patients with chronic obstructive pulmonary disease (COPD).

  • Limitations of use: not indicated for relief of acute bronchospasm.  

*generic available

1

Alvesco®

(ciclesonide)

Inhalation aerosol

Maintenance treatment of asthma as prophylactic therapy in adult and pediatric patients 12 years of age and older.

  • Limitations of use: not indicated for the relief of acute bronchospasm.

2

Arnuity Ellipta®

(fluticasone furoate)

Inhalation powder

Maintenance treatment of asthma in adult and pediatric patients aged 5 years and older.

  • Limitations of use: not indicated for the relief of acute bronchospasm.

3

Asmanex HFA®

(mometasone furoate)

Inhalation aerosol

Maintenance treatment of asthma as prophylactic therapy in patients 5 years of age and older.

  • Limitations of use: not indicated for the relief of acute bronchospasm.

4

Asmanex Twisthaler®

(mometasone furoate)

Inhalation powder  

Maintenance treatment of asthma as prophylactic therapy in adult and pediatric patients 4 years of age and older.

  • Limitations of use: not indicated for the relief of acute bronchospasm.

5

Flovent Diskus®

(fluticasone propionate)

Inhalation powder   

Maintenance treatment of asthma as prophylactic therapy in patients 4 years of age and older.

  • Limitations of use: not indicated for the relief of acute bronchospasm.

6

Flovent HFA®

(fluticasone propionate)

Inhalation aerosol      

Maintenance treatment of asthma as prophylactic therapy in adult and pediatric patients aged 4 years and older.

  • Limitations of use: not indicated for the relief of acute bronchospasm.  

7

QVAR RediHaler®

(beclomethasone dipropionate HFA)

Inhalation aerosol 

Maintenance treatment of asthma as prophylactic therapy in adult and pediatric patients 4 years of age and older.

  • Limitations of use: not indicated for the relief of acute bronchospasm.   

8

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

Asthma

Asthma is a respiratory disease of chronic airway inflammation that is characterized by variable symptoms of wheezing, shortness of breath, chest tightness and/or cough, and expiratory airflow due to bronchoconstriction, airway wall thickening, and increased mucus. Asthma affects an estimated 300 million people worldwide of all ages and imposes a substantial burden on patients, their families, the community and on healthcare systems. The long-term goals of asthma management from a clinical perspective are to achieve good symptom control and maintain normal activity levels along with minimizing the risk of asthma-related death, exacerbations, persistent airflow limitation and side-effects. It is also important to determine the patient's own goals regarding their asthma.(9,10)  

For the best outcomes, inhaled corticosteroid (ICS)-containing treatment should be started as soon as possible after the diagnosis of asthma is made. Current guidelines provide no preference on the specific type of ICS to use and note that recommendations for broad populations will be different compared to individual patients that need to consider their own goals and preferences, characteristics and phenotype, along with practical issues such as cost, adherence, and availability.(9,10)   

COPD

Long-term monotherapy with an inhaled corticosteroid (ICS) in not recommended for the treatment of chronic obstructive pulmonary disease (COPD). If there is an indication for an ICS, the preferred combination is long-acting-beta2 agonist (LABA) + long-acting muscarinic antagonist (LAMA) + ICS which can be administered as single or multiple inhaler therapy. If patients with COPD have features of asthma, treatment should always include an ICS. Guidelines do not recommend one type of ICS over another. Guidelines recommend the patient and the prescriber to make the decision together based on the patient's abilities, goals, and preferences with an emphasis on adherence to therapy.(11)    

Safety

ADVAIR DISKUS is contraindicated in the following:(1)

  • Primary treatment of status asthmaticus or other acute episodes of asthma or COPD where intensive measures are required.
  • Severe hypersensitivity to milk proteins or demonstrated hypersensitivity to fluticasone propionate, salmeterol, or any of the excipients.

Alvesco is contraindicated in the following:(2)

  • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
  • Patients with known hypersensitivity to ciclesonide or any of the ingredients of Alvesco. Rare cases of hypersensitivity reactions with manifestations such as angioedema, with swelling of the lips, tongue and pharynx, have been reported.

Arnuity Ellipta is contraindicated in the following:(3)

  • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
  • Severe hypersensitivity to milk proteins or demonstrated hypersensitivity to fluticasone furoate or any of the excipients.


Asmanex HFA is contraindicated in the primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.(4)

Asmanex Twisthaler is contraindicated ​​​​​​in the following:(5)

  • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
  • Patients with known hypersensitivity to milk proteins or any ingredients of Asmanex Twisthalers.

Flovent Diskus is contraindicated in the following:(6)

  • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
  • Severe hypersensitivity to milk proteins or demonstrated hypersensitivity to fluticasone propionate.

Flovent HFA is contraindicated in the following:(7)

  • Primary treatment of status asthmaticus or acute episodes of asthma requiring intensive measures.
  • Hypersensitivity to any ingredient.

 QVAR RediHaler is contraindicated in the following:(8)

  • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
  • Patients with known hypersensitivity to beclomethasone dipropionate or any of the ingredients in QVAR RediHaler. 

 

REFERENCES

Number

Reference

1

ADVAIR DISKUS prescribing information. GlaxoSmithKline. October 2020. 

2

Alvesco prescribing information. Covis Pharma. February 2023. 

3

Arnuity Ellipta prescribing information. GlaxoSmithKline.  March 2023.

4

Asmanex HFA prescribing information. Organon Global Inc.  June 2021  

5

Asmanex Twisthaler prescribing information. Merck & CO., INC. February 2021. 

6

Flovent Diskus prescribing information. GlaxoSmithKline. June 2022.   

7

Flovent HFA prescribing information. GlaxoSmithKline. August 2021. 

8

QVAR RediHaler prescribing information. Teva Respiratory, LLC. September 2022. 

9

Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske Jr., R. F., Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020, December). 2020 Focused updates to the Asthma Management Guidelines. National Heart Lung and Blood Institute (NHLBI). https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates 

10

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2023. www.ginasthma.org

11

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, 2023. https://goldcopd.org

POLICY AGENT SUMMARY STEP THERAPY

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Targeted MSC

Available MSC

Final Age Limit

Preferred Status

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 100-50 MCG/DOSE

100-50 MCG/ACT

M ; N ; O

O ; Y

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 250-50 MCG/DOSE

250-50 MCG/ACT

M ; N ; O

O ; Y

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 500-50 MCG/DOSE

500-50 MCG/ACT

M ; N ; O

O ; Y

Alvesco

ciclesonide inhal aerosol

160 MCG/ACT ; 80 MCG/ACT

M ; N ; O ; Y

N

Flovent diskus

fluticasone propionate aer pow ba

100 MCG/ACT ; 100 MCG/BLIST ; 250 MCG/ACT ; 250 MCG/BLIST ; 50 MCG/ACT ; 50 MCG/BLIST

M ; N ; O ; Y

M ; N

Flovent hfa

fluticasone propionate hfa inhal aer  ; fluticasone propionate hfa inhal aero

110 MCG/ACT ; 220 MCG/ACT ; 44 MCG/ACT

M ; N ; O ; Y

M ; N

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Indacaterol-Glycopyrrolate Inhal Cap 27.5-15.6 MCG

60

Capsules

30

DAYS

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 100-50 MCG/DOSE

100-50 MCG/ACT

1

Inhaler

30

DAYS

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 250-50 MCG/DOSE

250-50 MCG/ACT

1

Inhaler

30

DAYS

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 500-50 MCG/DOSE

500-50 MCG/ACT

1

Inhaler

30

DAYS

Advair hfa

Fluticasone-Salmeterol Inhal Aerosol 115-21 MCG/ACT

115-21 MCG/ACT

1

Inhaler

30

DAYS

Advair hfa

Fluticasone-Salmeterol Inhal Aerosol 230-21 MCG/ACT

230-21 MCG/ACT

1

Inhaler

30

DAYS

Advair hfa

Fluticasone-Salmeterol Inhal Aerosol 45-21 MCG/ACT

45-21 MCG/ACT

1

Inhaler

30

DAYS

Airduo digihaler 113/14

Fluticasone-Salmeterol Aer Powder BA

113-14 MCG/ACT

1

Inhaler

30

DAYS

Airduo digihaler 232/14

Fluticasone-Salmeterol Aer Powder BA

232-14 MCG/ACT

1

Inhaler

30

DAYS

Airduo digihaler 55/14

Fluticasone-Salmeterol Aer Powder BA

55-14 MCG/ACT

1

Inhaler

30

DAYS

Airduo respiclick 113/14

Fluticasone-Salmeterol Aer Powder BA 113-14 MCG/ACT

113-14 MCG/ACT

1

Inhaler

30

DAYS

Airduo respiclick 232/14

Fluticasone-Salmeterol Aer Powder BA 232-14 MCG/ACT

232-14 MCG/ACT

1

Inhaler

30

DAYS

Airduo respiclick 55/14

Fluticasone-Salmeterol Aer Powder BA 55-14 MCG/ACT

55-14 MCG/ACT

1

Inhaler

30

DAYS

Airsupra

albuterol-budesonide inhalation aerosol

90-80 MCG/ACT

3

Inhalers

30

DAYS

Alvesco

Ciclesonide Inhal Aerosol 160 MCG/ACT

160 MCG/ACT

2

Inhalers

30

DAYS

Alvesco

Ciclesonide Inhal Aerosol 80 MCG/ACT

80 MCG/ACT

1

Inhaler

30

DAYS

Anoro ellipta

Umeclidinium-Vilanterol Aero Powd BA 62.5-25 MCG/INH

62.5-25 MCG/ACT

1

Inhaler

30

DAYS

Armonair digihaler

Fluticasone Propionate Aer Pow BA

55 MCG/ACT

1

Inhaler

30

DAYS

Armonair digihaler

Fluticasone Propionate Aer Pow BA

113 MCG/ACT

1

Inhaler

30

DAYS

Armonair digihaler

Fluticasone Propionate Aer Pow BA

232 MCG/ACT

1

Inhaler

30

DAYS

Arnuity ellipta

Fluticasone Furoate Aerosol Powder Breath Activ 100 MCG/ACT

100 MCG/ACT

1

Inhaler

30

DAYS

Arnuity ellipta

Fluticasone Furoate Aerosol Powder Breath Activ 200 MCG/ACT

200 MCG/ACT

1

Inhaler

30

DAYS

Arnuity ellipta

Fluticasone Furoate Aerosol Powder Breath Activ 50 MCG/ACT

50 MCG/ACT

1

Inhaler

30

DAYS

Asmanex hfa

Mometasone Furoate Inhal Aerosol Suspension 100 MCG/ACT

100 MCG/ACT

1

Inhaler

30

DAYS

Asmanex hfa

Mometasone Furoate Inhal Aerosol Suspension 200 MCG/ACT

200 MCG/ACT

1

Inhaler

30

DAYS

Asmanex hfa

Mometasone Furoate Inhal Aerosol Suspension 50 MCG/ACT

50 MCG/ACT

1

Inhaler

30

DAYS

Asmanex twisthaler 120 me ; Asmanex twisthaler 14 met ; Asmanex twisthaler 30 met ; Asmanex twisthaler 60 met

Mometasone Furoate Inhal Powd 220 MCG/INH (Breath Activated)

220 MCG/INH

1

Inhaler

30

DAYS

Asmanex twisthaler 30 met ; Asmanex twisthaler 7 mete

Mometasone Furoate Inhal Powd 110 MCG/INH (Breath Activated)

110 MCG/INH

1

Inhaler

30

DAYS

Atrovent hfa

Ipratropium Bromide HFA Inhal Aerosol 17 MCG/ACT

17 MCG/ACT

2

Inhalers

30

DAYS

Bevespi aerosphere

Glycopyrrolate-Formoterol Fumarate Aerosol 9-4.8 MCG/ACT

9-4.8 MCG/ACT

1

Inhaler

30

DAYS

Breo ellipta

fluticasone furoate-vilanterol aero powd ba

50-25 MCG/INH

1

Inhaler

30

DAYS

Breo ellipta

Fluticasone Furoate-Vilanterol Aero Powd BA 100-25 MCG/INH

100-25 MCG/ACT

1

Inhaler

30

DAYS

Breo ellipta

Fluticasone Furoate-Vilanterol Aero Powd BA 200-25 MCG/INH

200-25 MCG/ACT

1

Inhaler

30

DAYS

Breyna ; Symbicort

Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT

160-4.5 MCG/ACT

3

Inhalers

30

DAYS

Breyna ; Symbicort

Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 MCG/ACT

80-4.5 MCG/ACT

3

Inhalers

30

DAYS

Breztri aerosphere

Budesonide-Glycopyrrolate-Formoterol Aers

160-9-4.8 MCG/ACT

1

Inhaler

30

DAYS

Combivent respimat

Ipratropium-Albuterol Inhal Aerosol Soln 20-100 MCG/ACT

20-100 MCG/ACT

2

Inhalers

30

DAYS

Duaklir pressair

Aclidinium Br-Formoterol Fum Aero Pow Br Act 400-12 MCG/ACT

400-12 MCG/ACT

1

Inhaler

30

DAYS

Dulera

Mometasone Furoate-Formoterol Fumarate Aerosol 100-5 MCG/ACT

100-5 MCG/ACT

3

Inhalers

30

DAYS

Dulera

Mometasone Furoate-Formoterol Fumarate Aerosol 200-5 MCG/ACT

200-5 MCG/ACT

3

Inhalers

30

DAYS

Dulera

Mometasone Furoate-Formoterol Fumarate Aerosol 50-5 MCG/ACT

50-5 MCG/ACT

3

Inhalers

30

DAYS

Flovent diskus

Fluticasone Propionate Aer Pow BA 100 MCG/BLISTER

100 MCG/ACT ; 100 MCG/BLIST

1

Inhaler

30

DAYS

Flovent diskus

Fluticasone Propionate Aer Pow BA 250 MCG/BLISTER

250 MCG/ACT ; 250 MCG/BLIST

4

Inhalers

30

DAYS

Flovent diskus

Fluticasone Propionate Aer Pow BA 50 MCG/BLISTER

50 MCG/ACT ; 50 MCG/BLIST

1

Inhaler

30

DAYS

Flovent hfa

Fluticasone Propionate HFA Inhal Aer 110 MCG/ACT (125/Valve)

110 MCG/ACT

1

Inhaler

30

DAYS

Flovent hfa

Fluticasone Propionate HFA Inhal Aer 220 MCG/ACT (250/Valve)

220 MCG/ACT

2

Inhalers

30

DAYS

Flovent hfa

Fluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve)

44 MCG/ACT

1

Inhaler

30

DAYS

Incruse ellipta

Umeclidinium Br Aero Powd Breath Act 62.5 MCG/INH (Base Eq)

62.5 MCG/INH

1

Inhaler

30

DAYS

Proair digihaler

Albuterol Sulfate Aer Pow BA

108 MCG/ACT

2

Inhalers

30

DAYS

Proair hfa ; Proventil hfa ; Ventolin hfa

Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv)

108  ; 108 MCG/ACT

2

Inhalers

30

DAYS

Proair respiclick

Albuterol Sulfate Aer Pow BA 108 MCG/ACT (90 MCG Base Equiv)

108 MCG/ACT

2

Inhalers

30

DAYS

Pulmicort flexhaler

Budesonide Inhal Aero Powd 180 MCG/ACT (Breath Activated)

180 MCG/ACT

2

Inhalers

30

DAYS

Pulmicort flexhaler

Budesonide Inhal Aero Powd 90 MCG/ACT (Breath Activated)

90 MCG/ACT

1

Inhaler

30

DAYS

Qvar redihaler

Beclomethasone Diprop HFA Breath Act Inh Aer 40 MCG/ACT

40 MCG/ACT

1

Inhaler

30

DAYS

Qvar redihaler

Beclomethasone Diprop HFA Breath Act Inh Aer 80 MCG/ACT

80 MCG/ACT

2

Inhalers

30

DAYS

Serevent diskus

Salmeterol Xinafoate Aer Pow BA 50 MCG/DOSE (Base Equiv)

50 MCG/DOSE

1

Inhaler

30

DAYS

Spiriva handihaler

Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv)

18 MCG

30

Capsules

30

DAYS

Spiriva respimat

Tiotropium Bromide Monohydrate Inhal Aerosol 1.25 MCG/ACT

1.25 MCG/ACT

1

Inhaler

30

DAYS

Spiriva respimat

Tiotropium Bromide Monohydrate Inhal Aerosol 2.5 MCG/ACT

2.5 MCG/ACT

1

Inhaler

30

DAYS

Stiolto respimat

Tiotropium Br-Olodaterol Inhal Aero Soln 2.5-2.5 MCG/ACT

2.5-2.5 MCG/ACT

1

Inhaler

30

DAYS

Striverdi respimat

Olodaterol HCl Inhal Aerosol Soln 2.5 MCG/ACT (Base Equiv)

2.5 MCG/ACT

1

Inhaler

30

DAYS

Trelegy ellipta

Fluticasone-Umeclidinium-Vilanterol AEPB

200-62.5-25 MCG/ACT

1

Inhaler

30

DAYS

Trelegy ellipta

Fluticasone-Umeclidinium-Vilanterol AEPB 100-62.5-25 MCG/INH

100-62.5-25 MCG/ACT

1

Inhaler

30

DAYS

Tudorza pressair

Aclidinium Bromide Aerosol Powd Breath Activated 400 MCG/ACT

400 MCG/ACT

1

Inhaler

30

DAYS

Xopenex hfa

Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv)

45 MCG/ACT

2

Inhalers

30

DAYS

Xopenex hfa

Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv)

45 MCG/ACT

2

Inhalers

30

DAYS

CLIENT SUMMARY – STEP THERAPY

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 100-50 MCG/DOSE

100-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 250-50 MCG/DOSE

250-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 500-50 MCG/DOSE

500-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alvesco

ciclesonide inhal aerosol

160 MCG/ACT ; 80 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent diskus

fluticasone propionate aer pow ba

100 MCG/ACT ; 100 MCG/BLIST ; 250 MCG/ACT ; 250 MCG/BLIST ; 50 MCG/ACT ; 50 MCG/BLIST

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent hfa

fluticasone propionate hfa inhal aer  ; fluticasone propionate hfa inhal aero

110 MCG/ACT ; 220 MCG/ACT ; 44 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Indacaterol-Glycopyrrolate Inhal Cap 27.5-15.6 MCG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 100-50 MCG/DOSE

100-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 250-50 MCG/DOSE

250-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair diskus ; Wixela inhub

Fluticasone-Salmeterol Aer Powder BA 500-50 MCG/DOSE

500-50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair hfa

Fluticasone-Salmeterol Inhal Aerosol 115-21 MCG/ACT

115-21 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair hfa

Fluticasone-Salmeterol Inhal Aerosol 230-21 MCG/ACT

230-21 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Advair hfa

Fluticasone-Salmeterol Inhal Aerosol 45-21 MCG/ACT

45-21 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Airduo digihaler 113/14

Fluticasone-Salmeterol Aer Powder BA

113-14 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Airduo digihaler 232/14

Fluticasone-Salmeterol Aer Powder BA

232-14 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Airduo digihaler 55/14

Fluticasone-Salmeterol Aer Powder BA

55-14 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Airduo respiclick 113/14

Fluticasone-Salmeterol Aer Powder BA 113-14 MCG/ACT

113-14 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Airduo respiclick 232/14

Fluticasone-Salmeterol Aer Powder BA 232-14 MCG/ACT

232-14 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Airduo respiclick 55/14

Fluticasone-Salmeterol Aer Powder BA 55-14 MCG/ACT

55-14 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Airsupra

albuterol-budesonide inhalation aerosol

90-80 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alvesco

Ciclesonide Inhal Aerosol 160 MCG/ACT

160 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alvesco

Ciclesonide Inhal Aerosol 80 MCG/ACT

80 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Anoro ellipta

Umeclidinium-Vilanterol Aero Powd BA 62.5-25 MCG/INH

62.5-25 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Armonair digihaler

Fluticasone Propionate Aer Pow BA

113 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Armonair digihaler

Fluticasone Propionate Aer Pow BA

232 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Armonair digihaler

Fluticasone Propionate Aer Pow BA

55 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Arnuity ellipta

Fluticasone Furoate Aerosol Powder Breath Activ 100 MCG/ACT

100 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Arnuity ellipta

Fluticasone Furoate Aerosol Powder Breath Activ 200 MCG/ACT

200 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Arnuity ellipta

Fluticasone Furoate Aerosol Powder Breath Activ 50 MCG/ACT

50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Asmanex hfa

Mometasone Furoate Inhal Aerosol Suspension 100 MCG/ACT

100 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Asmanex hfa

Mometasone Furoate Inhal Aerosol Suspension 200 MCG/ACT

200 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Asmanex hfa

Mometasone Furoate Inhal Aerosol Suspension 50 MCG/ACT

50 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Asmanex twisthaler 120 me ; Asmanex twisthaler 14 met ; Asmanex twisthaler 30 met ; Asmanex twisthaler 60 met

Mometasone Furoate Inhal Powd 220 MCG/INH (Breath Activated)

220 MCG/INH

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Asmanex twisthaler 30 met ; Asmanex twisthaler 7 mete

Mometasone Furoate Inhal Powd 110 MCG/INH (Breath Activated)

110 MCG/INH

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Atrovent hfa

Ipratropium Bromide HFA Inhal Aerosol 17 MCG/ACT

17 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Bevespi aerosphere

Glycopyrrolate-Formoterol Fumarate Aerosol 9-4.8 MCG/ACT

9-4.8 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Breo ellipta

fluticasone furoate-vilanterol aero powd ba

50-25 MCG/INH

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Breo ellipta

Fluticasone Furoate-Vilanterol Aero Powd BA 100-25 MCG/INH

100-25 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Breo ellipta

Fluticasone Furoate-Vilanterol Aero Powd BA 200-25 MCG/INH

200-25 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Breyna ; Symbicort

Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT

160-4.5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Breyna ; Symbicort

Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 MCG/ACT

80-4.5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Breztri aerosphere

Budesonide-Glycopyrrolate-Formoterol Aers

160-9-4.8 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Combivent respimat

Ipratropium-Albuterol Inhal Aerosol Soln 20-100 MCG/ACT

20-100 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Duaklir pressair

Aclidinium Br-Formoterol Fum Aero Pow Br Act 400-12 MCG/ACT

400-12 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Dulera

Mometasone Furoate-Formoterol Fumarate Aerosol 100-5 MCG/ACT

100-5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Dulera

Mometasone Furoate-Formoterol Fumarate Aerosol 200-5 MCG/ACT

200-5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Dulera

Mometasone Furoate-Formoterol Fumarate Aerosol 50-5 MCG/ACT

50-5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent diskus

Fluticasone Propionate Aer Pow BA 100 MCG/BLISTER

100 MCG/ACT ; 100 MCG/BLIST

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent diskus

Fluticasone Propionate Aer Pow BA 250 MCG/BLISTER

250 MCG/ACT ; 250 MCG/BLIST

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent diskus

Fluticasone Propionate Aer Pow BA 50 MCG/BLISTER

50 MCG/ACT ; 50 MCG/BLIST

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent hfa

Fluticasone Propionate HFA Inhal Aer 110 MCG/ACT (125/Valve)

110 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent hfa

Fluticasone Propionate HFA Inhal Aer 220 MCG/ACT (250/Valve)

220 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Flovent hfa

Fluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve)

44 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Incruse ellipta

Umeclidinium Br Aero Powd Breath Act 62.5 MCG/INH (Base Eq)

62.5 MCG/INH

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Proair digihaler

Albuterol Sulfate Aer Pow BA

108 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Proair hfa ; Proventil hfa ; Ventolin hfa

Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv)

108  ; 108 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Proair respiclick

Albuterol Sulfate Aer Pow BA 108 MCG/ACT (90 MCG Base Equiv)

108 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pulmicort flexhaler

Budesonide Inhal Aero Powd 180 MCG/ACT (Breath Activated)

180 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pulmicort flexhaler

Budesonide Inhal Aero Powd 90 MCG/ACT (Breath Activated)

90 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Qvar redihaler

Beclomethasone Diprop HFA Breath Act Inh Aer 40 MCG/ACT

40 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Qvar redihaler

Beclomethasone Diprop HFA Breath Act Inh Aer 80 MCG/ACT

80 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Serevent diskus

Salmeterol Xinafoate Aer Pow BA 50 MCG/DOSE (Base Equiv)

50 MCG/DOSE

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Spiriva handihaler

Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv)

18 MCG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Spiriva respimat

Tiotropium Bromide Monohydrate Inhal Aerosol 1.25 MCG/ACT

1.25 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Spiriva respimat

Tiotropium Bromide Monohydrate Inhal Aerosol 2.5 MCG/ACT

2.5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Stiolto respimat

Tiotropium Br-Olodaterol Inhal Aero Soln 2.5-2.5 MCG/ACT

2.5-2.5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Striverdi respimat

Olodaterol HCl Inhal Aerosol Soln 2.5 MCG/ACT (Base Equiv)

2.5 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Trelegy ellipta

Fluticasone-Umeclidinium-Vilanterol AEPB

200-62.5-25 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Trelegy ellipta

Fluticasone-Umeclidinium-Vilanterol AEPB 100-62.5-25 MCG/INH

100-62.5-25 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tudorza pressair

Aclidinium Bromide Aerosol Powd Breath Activated 400 MCG/ACT

400 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xopenex hfa

Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv)

45 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xopenex hfa

Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv)

45 MCG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

STEP THERAPY CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Advair Diskus

TARGET AGENT(S)

PREREQUISITE AGENT(S)

Advair Diskus*

fluticasone propionate-salmeterol aerosol powder generic 

*generic available

 

Target Agent(s) will be approved when ONE of the following is met:

  1. The patient has a medication history of use of ONE prerequisite agent within the past 90 days OR
  2. The patient has an intolerance or hypersensitivity to ONE prerequisite agent
  3. The patient has an FDA labeled contraindication to ALL prerequisite agents

Length of Approval: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit criteria.

*Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required.

Alvesco, Flovent/fluticasone

TARGET AGENT(S)

PREREQUISITE AGENT(S)

REQUIRED NUMBER OF PREREQUISITES AND LOOK BACK TIMEFRAME

Alvesco
Flovent Diskus
Flovent HFA
Fluticasone propionate aerosol inhalation

Arnuity Ellipta
Asmanex HFA
Asmanex Twisthaler
Qvar HFA

1 prerequisite within the past 90 days



Target Agent(s) will be approved when ONE of the following is met:

  1. The patient has a medication history of use of ONE prerequisite agent within the past 90 days OR
  2. The patient has an intolerance or hypersensitivity to ONE prerequisite agent OR
  3. The patient has an FDA labeled contraindication to ALL prerequisite agents

Length of Approval: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit criteria.

*Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required.

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

QL

Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
    2. BOTH of the following:
      1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication

Length of Approval: up to 12 months 

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

ALBP _  Commercial _ CSReg _ Oral_Inhalers_STQL _ProgSum_ 04-01-2024  _© Copyright Prime Therapeutics LLC. January 2024 All Rights Reserved