Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

mometasone nasal spray

Criteria

Approval Period

Diagnosis of allergic rhinitis
PLUS
person between ages three to eleven years.
Up to person's twelfth birthday.

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)

Online Forms (PDF, 524KB)
Click on the link to complete a special authority request form.