Odactra — Highmark

allergic rhinitis (with or without conjunctivitis) due to house dust mites (Dermatophagoides pteronyssinus or D. farinae)

Initial criteria

age between 5 and 65 years
diagnosis of allergic rhinitis (ICD-10: J30.2, J30.8, J30.9) due to house dust mites
allergic rhinitis with or without conjunctivitis confirmed by in vitro testing for IgE antibodies to D. pteronyssinus or D. farinae OR skin testing for licensed house dust mite allergen extracts
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

prescriber documentation that the member has experienced improvement in allergy symptoms

12 months