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

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