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Coverage criteria policies

Sublingual immunotherapy (SLIT)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for sublingual immunotherapy tablets through Pharmacy Administration.

Coverage

Sublingual tablets to treat allergies require prior authorization through Pharmacy Administration. Refer to the HealthPartners formulary website for details.

Indications that are covered

Refer to the HealthPartners formulary website for formulary status and prior authorization criteria for sublingual immunotherapy tablets.

Indications that are not covered

Single or compounded allergy drops for allergy treatment are considered investigational and not covered.

Definitions

Sublingual drops are allergen extracts held under the tongue (sublingual). These are not approved by the FDA.

Sublingual immunotherapy (SLIT) refers to allergy testing and treatment performed under the tongue.

Sublingual tablets are FDA-approved for the treatment of pollen-induced allergic rhinitis.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:

Codes

Description

95199

Unlisted allergy/clinical immunologic service or procedure

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 11/21/2014 - Date of origin
  • 04/28/2017 - Effective date
Review date
  • 02/2018

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