Grastek (Timothy grass pollen allergen extract) — United Healthcare
grass pollen-induced allergic rhinitis
Initial criteria
- Diagnosis of grass pollen-induced allergic rhinitis
- Diagnosis confirmed by ONE of the following: (a) Positive skin test to Timothy grass or cross-reactive grass pollens (e.g., Sweet Vernal, Orchard/Cocksfoot, Perennial Rye, Kentucky Blue/June grass, Meadow Fescue, or Redtop) OR (b) in vitro testing for pollen-specific IgE antibodies for Timothy grass or cross-reactive grass pollens (e.g., Sweet Vernal, Orchard/Cocksfoot, Perennial Rye, Kentucky Blue/June grass, Meadow Fescue, or Redtop)
- Treatment is started or will be started at least 12 weeks before the expected onset of the grass pollen season
Reauthorization criteria
- Documentation of positive clinical response to Grastek therapy
Approval duration
12 months