Limited coverage criteria – mometasone nasal spray

Last updated on April 2, 2025

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Generic name		mometasone nasal spray
Strength & form		50 mcg/spray

Special Authority criteria	Approval period
For patients between ages 3 to 11 years with a diagnosis of allergic rhinitis	Until the patient's 12th birthday

Practitioner exemptions

None

Special Authority request form(s)

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HLTH 5328 – General Special Authority request (PDF, 656KB)

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Limited coverage criteria – mometasone nasal spray

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special Authority request form(s)