Grastek — Highmark
allergic rhinitis (with or without conjunctivitis) due to Timothy grass pollen or cross-reactive grass pollens (Sweet Vernal, Orchard, Perennial Rye, Timothy, Kentucky Blue Grass pollen, Redtop, or meadow fescue)
Initial criteria
- age between 5 and 65 years
- diagnosis of allergic rhinitis (ICD-10: J30.1, J30.2, J30.8, J30.9) due to Timothy grass pollen or cross-reactive grass pollens
- allergic rhinitis with or without conjunctivitis confirmed by a positive pollen-specific skin test OR in vitro testing for pollen-specific IgE antibodies
- therapeutic failure, contraindication, or intolerance to an intranasal steroid AND one of the following: (i) an oral non-sedating antihistamine, (ii) an intranasal antihistamine, or (iii) an intranasal anticholinergic agent
- concurrent prescription for an epinephrine auto-injector
Reauthorization criteria
- prescriber documentation that the member has experienced improvement in allergy symptoms
Approval duration
12 months