CurrentBlue Cross Blue Shield - MassachusettsPolicy 681

Sublingual immunotherapy (SLIT) oral tablets for allergic rhinitis

Defines prior authorization, coverage criteria, and pharmacy benefit handling for specific SLIT oral tablet products (Grastek, Odactra, Oralair, Ragwitek) for commercial BCBSMA members; applies to retail pharmacy dispensing and specifies prescriber and testing requirements.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicySublingual immunotherapy (SLIT) oral tablets for allergic rhinitis

Policy CodePolicy 681

Change TypeAge indication and prescriber/testing clarifications

Effective Date

Next Review Date

Key ActionSubmit prior authorization to BCBSMA Pharmacy Operations for Grastek, Odactra, Oralair, or Ragwitek with required clinical documentation and prescriber/testing confirmation.

SourceLink

POLICY UPDATE CHANGES

Updated age indication for Odactra and Oralair.

Clarified that prescribers must be board certified/eligible allergists or otolaryngologists or there must be confirmatory testing.

Stated that all SLIT products are excluded from mail order and are retail pharmacy only.

4SLIT products named

5-65Typical age range

PA requiredFormulary status

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Coverage Criteria for SLIT Oral Tablets

Product-specific coverage criteria

Covered when ALL of the following are met for each product (product-specific conditions follow):

Grastek (Timothy grass) coverage: For use in persons 5 through 65 years of age; used as immunotherapy for the treatment of grass pollen-induced allergic rhinitis with or without conjunctivitis caused by Timothy grass or cross-reactive grass pollens; prescribed by a board certified or board eligible allergist or board certified or board eligible otolaryngologist OR confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies; approvals limited to start the time period needed before the expected onset of the allergy-inducing pollen season and continued throughout the pollen season.age 5-65

Retail pharmacy only; PA required

Odactra (house dust mite) coverage: Used as immunotherapy for the treatment of house dust mite (Dermatophagoides pteronyssinus and Dermatophagoides farinae)-induced allergic rhinitis with or without conjunctivitis; prescribed by a board certified or board eligible allergist or board certified or board eligible otolaryngologist OR confirmed by positive skin test or in vitro testing for specific IgE; for use in persons 5 through 65 years of age; approvals limited to start the time period needed before the expected onset of the allergy-inducing season and continued throughout the relevant treatment period.age 5-65

Retail pharmacy only; PA required

Oralair (multi-grass) coverage: Used as immunotherapy for the treatment of grass pollen-induced allergic rhinitis with or without conjunctivitis; prescribed by a board certified or board eligible allergist or board certified or board eligible otolaryngologist OR confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies; for use in persons 5 through 65 years of age; approvals limited to start the time period needed before the expected onset of the allergy-inducing pollen season and continued throughout the pollen season.age 5-65

Retail pharmacy only; PA required

Ragwitek (short ragweed) coverage: Prescribed by a board certified or board eligible allergist or board certified or board eligible otolaryngologist OR confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies; used as immunotherapy for the treatment of short ragweed (Ambrosia artemisiifolia) pollen-induced allergic rhinitis with or without conjunctivitis; for use in persons 5 through 65 years of age; approvals limited to start the time period needed before the expected onset of the allergy-inducing pollen season and continued throughout the pollen season.age 5-65

Retail pharmacy only; PA required

The policy does not provide coverage for the listed sublingual immunotherapy oral tablet products when they are prescribed for conditions other than those specifically enumerated in the product-specific coverage criteria. In addition, SLIT products are excluded from mail order and must be dispensed through retail pharmacies per BCBSMA pharmacy operations.

Requests that are based solely on the use of samples will not meet the coverage criteria. Additional clinical information demonstrating medical necessity for the requested medication must be submitted by the requesting prescriber for review.

Coding and Indications

CPT Codes (informational)CPT

No specific CPT

There is no specific CPT code for this service.

Age indication

Typical age rangeFor listed products: 5 through 65 years of age

Age on Odactra and OralairConfirmed as 5 through 65 years (policy update reflected)

Age requirement per product criteriaAge must be documented in clinical submission to meet coverage criteria

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for listed SLIT products

Prior authorization is required for Grastek, Odactra, Oralair, and Ragwitek; coverage is processed through BCBSMA Pharmacy Operations for retail pharmacy dispensing when criteria are met.

Formulary status for GRASTEK, ODACTRA, ORALAIR, and RAGWITEK = PA Required.
Requests for retail pharmacy coverage are handled via Blue Cross Blue Shield of Massachusetts Pharmacy Operations (phone/fax or PA form).

Step Therapy

Step therapy / Quality Care Dosing applies

Step therapy / Quality Care Dosing applies as part of the prior authorization process; providers should follow Pharmacy Operations instructions for specific step or formulary requirements.

Step status and formulary details are listed in the policy and managed through Pharmacy Operations.
Contact Pharmacy Operations for step therapy procedures and prior authorization submission.

Product Definitions

SLIT products and allergen targets

GrastekTimothy grass pollen allergen

OdactraDermatophagoides pteronyssinus and Dermatophagoides farinae (house dust mite)

OralairMulti-grass pollen mix (includes Anthoxanthum odoratum, Dactylis glomerata, Lolium perenne, Phleum pratense, Poa pratensis)

RagwitekShort ragweed (Ambrosia artemisiifolia) pollen

Background

Sublingual immunotherapy oral tablets (SLIT) are used as allergen-specific immunotherapy to treat allergic rhinitis with or without conjunctivitis caused by specific pollen or dust mite allergens. These products are intended to be initiated and continued according to product labeling and relevant seasonal timing, and coverage is limited to the indications listed in the policy. Prescriber qualifications and confirmatory allergy testing are components of the coverage requirements.