Odactra — United Healthcare

Initial criteria

• Diagnosis of house dust mite (HDM)-induced allergic rhinitis
• Diagnosis confirmed by one of the following: Positive skin test to licensed house dust mite allergen extracts OR in vitro testing for IgE antibodies to Dermatophagoides farinae or Dermatophagoides pteronyssinus house dust mites
• History of failure, contraindication, or intolerance to two of the following: oral antihistamine [e.g., cetirizine (Zyrtec)] AND/OR intranasal antihistamine [e.g., azelastine (Astelin)] AND/OR intranasal corticosteroid [e.g., fluticasone (Flonase)] AND/OR leukotriene inhibitor [e.g., montelukast (Singulair)]
• Patient does not have unstable and/or uncontrolled asthma
• Prescribed by or in consultation with a specialist in allergy and immunology

Reauthorization criteria

• Documentation of positive clinical response to Odactra therapy

Approval duration

12 months