CurrentCareSource Georgia MedicaidPolicy GA-MED-P-366579

Xolair (omalizumab) Coverage Criteria

Customize your policy alerts

Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

Get alerted when Policy GA-MED-P-366579 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs CareSource Georgia Medicaid coverage and prior authorization for Xolair (omalizumab) used for chronic rhinosinusitis with nasal polyps, chronic spontaneous urticaria, moderate-to-severe persistent asthma, and IgE-mediated food allergy. It establishes indication-specific clinical criteria, dosing limits, documentation requirements, initial authorization periods, and reauthorization requirements.

Policy Summary

PayerCareSource Georgia Medicaid

PolicyXolair (omalizumab) Coverage Criteria

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial clinical and coverage update

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization documentation meeting the indication-specific clinical criteria and dosing limits for Xolair coverage.

SourceLink

POLICY UPDATE CHANGES

IgE-mediated food allergy was added as a covered Xolair indication.

Chronic rhinosinusitis with nasal polyps criteria were revised to require at least two qualifying symptoms for 12 weeks or more.

Chronic spontaneous urticaria terminology and authorization criteria were updated.

4Covered Xolair indications

6 monthsCRSwNP and CSU initial authorization

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCareSource Georgia MedicaidPolicy GA-MED-P-366579

Xolair (omalizumab) Coverage Criteria

Customize your policy alerts

Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

Get alerted when Policy GA-MED-P-366579 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCareSource Georgia Medicaid

PolicyXolair (omalizumab) Coverage Criteria

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial clinical and coverage update

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization documentation meeting the indication-specific clinical criteria and dosing limits for Xolair coverage.

SourceLink

POLICY UPDATE CHANGES

IgE-mediated food allergy was added as a covered Xolair indication.

Chronic rhinosinusitis with nasal polyps criteria were revised to require at least two qualifying symptoms for 12 weeks or more.

Chronic spontaneous urticaria terminology and authorization criteria were updated.

4Covered Xolair indications

6 monthsCRSwNP and CSU initial authorization

16 weeksAsthma and food allergy initial authorization

12 monthsAdditional authorization after reauthorization

75-600 mgMaximum dose range for CRSwNP and food allergy

6 yearsYoungest asthma indication age

Indication-Specific Coverage Criteria

CRSwNP Initial Therapy

Covered when ALL of the following criteria are met:

ALL of the following

Member is at least 18 years of age.
Medication is prescribed by or in consultation with an allergist, immunologist, or otorhinolaryngologist (ENT).
At least TWO of the following symptoms have been present for 12 weeks or more:
- Nasal blockage, obstruction, or congestion.
- Nasal discharge.
- Facial pain or pressure.
- Reduction in smell.
Chart notes document bilateral nasal polyps by direct examination, endoscopy, or sinus CT scan.
The member's weight in kilograms and baseline serum IgE level in IU/mL are documented in the chart notes.
Chronic rhinosinusitis symptoms persist after treatment with:
- At least a 4-week trial of an intranasal corticosteroid, such as mometasone or fluticasone, in combination with nasal saline irrigation.
- At least ONE of the following:
  - Prior sinonasal surgery.
  - Systemic corticosteroids.
Medication is used as an add-on maintenance treatment in combination with an intranasal corticosteroid.
Medication is not used in combination with other biologic therapies for CRSwNP.
Dosage is 75 mg to 600 mg subcutaneously every 2 or 4 weeks, based on serum total IgE level measured before treatment and body weight, according to the dose determination chart in the package insert.

CRSwNP Continuation Therapy

Covered when ALL of the following criteria are met:

ALL of the following

Medication is used as add-on maintenance therapy in combination with intranasal corticosteroids.
Chart notes document improvement of signs and symptoms, such as reduced postnasal drip, reduced nasal polyp size, and/or reduced nasal congestion symptoms.

CSU Initial Therapy

Covered when ALL of the following criteria are met:

ALL of the following

Member is at least 12 years of age.
Medication is prescribed by or under the recommendation of an allergist, dermatologist, or immunologist.
Member has a diagnosis of moderate to severe chronic spontaneous urticaria, with wheals, angioedema, or both, present for more than 6 weeks.
Member has trialed and failed a second-generation H1 antihistamine, such as loratadine, cetirizine, or fexofenadine, at 2 to 4 times the FDA-approved dosage for 14 days.
Member will continue to use a second-generation H1 antihistamine with Xolair.

CSU Continuation Therapy

Covered when the following criterion is met:

ALL of the following

Chart notes support a positive clinical response, such as reduction in itch severity and/or hive count.

Asthma Initial Therapy

Covered when ALL of the following criteria are met:

ALL of the following

Member is at least 6 years of age.
Medication is prescribed by or in consultation with an allergist, immunologist, or pulmonologist.
At least ONE of the following allergy-testing criteria is met:
- Positive skin testing for a perennial aeroallergen.
- Reactivity to at least one aeroallergen documented by an elevated serum IgE level.
The member's weight is documented and baseline plasma immunoglobulin E (IgE) is at least 30 IU/mL.

Asthma Continuation Therapy

Covered when ALL of the following criteria are met:

ALL of the following

Medication is not used as monotherapy for asthma.
Chart notes show improvement by at least ONE of the following:
- Decreased frequency of emergency department visits or hospitalizations due to asthma exacerbations.
- Improved functional ability, including decreased effect of asthma on exercise, school or work function, or quality of sleep.
- Decreased utilization of rescue medications or oral corticosteroids.

Food Allergy Initial Therapy

Covered when ALL of the following criteria are met:

ALL of the following

Member is at least 1 year of age.
Medication is prescribed by or in consultation with an allergist or immunologist.
Member has a diagnosis of IgE-mediated food allergy confirmed by clinical history of allergic reactions.
Chart notes document a positive skin prick test or positive serum IgE.
The member's weight in kilograms and baseline serum IgE level in IU/mL are documented in the chart notes.

Food Allergy Continuation Therapy

Covered when ALL of the following criteria are met:

ALL of the following

Provider attests that medication will continue to be used with food allergen avoidance.
Chart notes show that the member is clinically benefiting from therapy and has not had anaphylaxis requiring advanced medical care.

For CRSwNP, asthma, and food allergy indications, the medication must not be used concurrently with another biologic therapy when the applicable indication-specific criteria prohibit concurrent biologic use. For food allergy, the medication must not be used with Palforzia.

CareSource considers Xolair (omalizumab) not medically necessary for the treatment of conditions that are not listed in this document. For any other indication, refer to the Off-Label policy.

Clinical Thresholds and Coding Reference

Asthma baseline IgE threshold

Baseline testPlasma immunoglobulin E (IgE) level

Minimum level30 IU/mL or higher

DocumentationBaseline plasma IgE must be documented for asthma authorization

CRSwNP symptom duration threshold

Qualifying symptomsAt least 2 CRSwNP symptoms

Minimum duration12 weeks or more

ExamplesNasal blockage, nasal discharge, facial pain or pressure, or reduced sense of smell

Authorization, Documentation, and Denial Risks

Prior Authorization

Initial Authorization Required

Prior authorization is required for Xolair (omalizumab). The provider must submit the indication-specific criteria, required clinical documentation, dosing information, and applicable authorization period before treatment is approved.

Initial authorization periods: CRSwNP and CSU—6 months; asthma and IgE-mediated food allergy—16 weeks.
Dosing must follow the package-insert dose determination chart using pretreatment serum total IgE and body weight.
Approved dosing ranges: CRSwNP and food allergy 75–600 mg subcutaneously every 2 or 4 weeks; CSU 150 or 300 mg subcutaneously every 4 weeks; asthma 75–375 mg subcutaneously every 2 or 4 weeks.

Prior Authorization

Reauthorization Required

Reauthorization is required for continued Xolair therapy. Submit evidence that the member remains on appropriate therapy and has demonstrated clinical benefit during the prior authorization period.

CRSwNP, CSU, asthma, and food allergy each require subsequent authorization.

Policy Background

Xolair (omalizumab) is an anti-IgE monoclonal antibody used for selected allergic and inflammatory conditions. This policy covers Xolair as add-on treatment for chronic rhinosinusitis with nasal polyps, chronic spontaneous urticaria, moderate-to-severe persistent asthma, and IgE-mediated food allergy. Coverage depends on the applicable age, specialist involvement, disease severity or diagnostic confirmation, prior therapy, laboratory values, dosing parameters, and documented response for continuation.

Covered Condition Definitions

CRSwNP definition

ConditionChronic inflammatory condition involving the sinuses

Anatomic findingBilateral nasal polyps

Qualifying symptomsAt least 2 symptoms, including nasal obstruction or congestion, nasal discharge, facial pain or pressure, or reduced sense of smell, persisting for 12 weeks or more

CSU definition

ConditionModerate-to-severe chronic spontaneous urticaria

ManifestationsSpontaneous wheals, angioedema, or both

Duration

Initial Authorization Criteria

CRSwNP Initial Criteria

CRSwNP initial authorization requires ALL listed clinical criteria.

ALL listed clinical criteria

Member is at least 18 years of age.
Medication is prescribed by or in consultation with an allergist, immunologist, or otorhinolaryngologist (ENT).
At least TWO symptoms for 12 weeks or more
- Nasal blockage, obstruction, or congestion.
- Nasal discharge.

Reauthorization Criteria

CRSwNP Continuation Criteria

CRSwNP reauthorization requires ALL of the following.

ALL of the following

Continue Xolair as add-on maintenance therapy with an intranasal corticosteroid.
Document improvement in signs or symptoms.12 additional months
Examples include reduced postnasal drip, reduced nasal polyp size, or reduced nasal congestion.

CSU Continuation Criteria

CSU reauthorization requires the following.

Required criterion

Required Prerequisite Therapy

Step	Required therapy	Duration	Coverage requirement
1	Intranasal corticosteroid, such as mometasone or fluticasone, in combination with nasal saline irrigation, plus prior sinonasal surgery or systemic corticosteroids	At least 4 weeks	Persistent CRSwNP symptoms after treatment

Step	Required therapy	Duration	Coverage requirement
1	Second-generation H1 antihistamine, such as loratadine, cetirizine, or fexofenadine, at 2–4 times the FDA-approved dosage	14 days	Trialed and failed antihistamine therapy

Step	Required therapy	Duration	Coverage requirement
1	Medium- to high-dose inhaled corticosteroid plus long-acting beta-2 agonist conventional therapy	3 months	Asthma remains inadequately controlled after treatment

Dosing and Quantity Limits

Xolair dosing for CRSwNP

Dose range75 mg to 600 mg

Route and frequencySubcutaneously every 2 or 4 weeks

Dose determinationBased on serum total IgE measured before treatment and body weight; use the package-insert dose determination chart

Xolair dosing for CSU

Dose options150 mg or 300 mg

RouteSubcutaneous injection

FrequencyEvery 4 weeks

Policy Summary

PayerCareSource Georgia Medicaid

PolicyXolair (omalizumab) Coverage Criteria

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial clinical and coverage update

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization documentation meeting the indication-specific clinical criteria and dosing limits for Xolair coverage.

SourceLink

On This Page

Dosage is 150 mg or 300 mg by subcutaneous injection every 4 weeks.

At least ONE of the following exacerbation criteria is met:

At least two documented severe asthma exacerbations requiring oral corticosteroids within the last year.
At least one documented severe asthma exacerbation requiring hospitalization within the last year.

Asthma has been inadequately controlled after 3 months of conventional treatment with medium to high doses of inhaled corticosteroids (ICS) and long-acting beta 2-agonists (LABA).

Medication is used as add-on maintenance treatment to conventional asthma therapies, such as ICS and LABA.

Medication is not used in conjunction with any other biologic therapy for asthma.

Dosage is 75 mg to 375 mg by subcutaneous injection every 2 or 4 weeks, based on serum total IgE level measured before treatment and body weight, according to the dose determination chart in the package insert.

Provider attests that medication will be used concomitantly with food allergen avoidance.

Medication will not be used with Palforzia.

Dosage is 75 mg to 600 mg subcutaneously every 2 or 4 weeks, based on serum total IgE level measured before treatment and body weight, according to the dose determination chart in the package insert.

CRSwNP intranasal corticosteroid trial

Required therapyIntranasal corticosteroid in combination with nasal saline irrigation

Minimum trialAt least 4 weeks

Failure criterionChronic rhinosinusitis symptoms persist after the trial

Asthma conventional treatment trial

Required therapyMedium- to high-dose inhaled corticosteroids and long-acting beta 2-agonists

Minimum trial3 months

Failure criterionAsthma remains inadequately controlled after conventional treatment

Asthma severe exacerbation thresholds

Oral corticosteroid thresholdAt least 2 severe exacerbations requiring oral corticosteroids

Hospitalization thresholdAt least 1 severe exacerbation requiring hospitalization

Look-back periodWithin the last year

CSU duration threshold

ConditionModerate-to-severe chronic spontaneous urticaria

Minimum durationMore than 6 weeks

Qualifying manifestationsWheals, angioedema, or both

CSU antihistamine trial

Medication classSecond-generation H1 antihistamine

Treatment duration14 days

Dose2-4 times the FDA-approved dosage

Each reauthorization period is an additional 12 months when all applicable criteria are met.

Step Therapy

CRSwNP Prerequisite Therapy

For CRSwNP, document persistent symptoms after appropriate prerequisite treatment before requesting initial authorization. Xolair must be used as add-on maintenance therapy with an intranasal corticosteroid.

At least a 4-week trial of an intranasal corticosteroid, such as mometasone or fluticasone, in combination with nasal saline irrigation is required.
Symptoms must persist after the trial and one of the following: prior sinonasal surgery or systemic corticosteroids.
Xolair must not be combined with another biologic therapy for CRSwNP.

Step Therapy

CSU Antihistamine Failure

For CSU, document failure of a second-generation H1 antihistamine before requesting Xolair. The member must continue the antihistamine with Xolair.

Trial must be at 2–4 times the FDA-approved dosage for 14 days.
Examples include loratadine, cetirizine, and fexofenadine.

Step Therapy

Asthma Conventional Therapy Failure

For asthma, document inadequate control despite conventional inhaled therapy before requesting Xolair. Xolair must be added to, not substituted for, conventional asthma treatment.

Asthma must remain inadequately controlled after 3 months of medium- to high-dose inhaled corticosteroid therapy with a long-acting beta-2 agonist.
Xolair must be used as add-on maintenance treatment with conventional therapies, such as ICS and LABA.
Xolair must not be used with another biologic therapy for asthma.

Documentation Required

CRSwNP Clinical Documentation

For initial CRSwNP authorization, submit clinical documentation supporting the diagnosis, severity, treatment history, and required specialist involvement.

Member must be at least 18 years old and the medication must be prescribed by or used in consultation with an allergist, immunologist, or otorhinolaryngologist (ENT).
Document at least 2 symptoms present for 12 weeks or more: nasal blockage/obstruction/congestion, nasal discharge, facial pain/pressure, or reduced smell.
Document bilateral nasal polyps by direct examination, endoscopy, or sinus CT scan.
Record weight in kilograms and baseline serum IgE in IU/mL.
Document the required intranasal corticosteroid plus saline trial and prior sinonasal surgery or systemic corticosteroid treatment.

Documentation Required

CRSwNP Response Documentation

For CRSwNP reauthorization, provide chart-note evidence that the member is benefiting from continued add-on treatment with an intranasal corticosteroid.

Document improvement such as reduced postnasal drip, reduced nasal polyp size, and/or reduced nasal congestion symptoms.

Documentation Required

CSU Clinical Documentation

For CSU initial authorization, submit records establishing the diagnosis, severity, duration, specialist management, and required antihistamine treatment failure.

Member must be at least 12 years old and treatment must be prescribed by or under the recommendation of an allergist, dermatologist, or immunologist.
Document moderate-to-severe chronic spontaneous urticaria with wheals, angioedema, or both, present for more than 6 weeks.
Document the second-generation H1 antihistamine trial at 2–4 times the FDA-approved dosage for 14 days and the plan to continue it with Xolair.

Documentation Required

CSU Response Documentation

For CSU reauthorization, provide chart notes demonstrating a positive clinical response to Xolair.

Document reduction in itch severity and/or hive count.

Documentation Required

Asthma Clinical Documentation

For initial asthma authorization, submit documentation supporting allergic asthma, disease severity, prior treatment, and specialist management.

Member must be at least 6 years old and treatment must be prescribed by or in consultation with an allergist, immunologist, or pulmonologist.
Document positive skin testing for a perennial aeroallergen or reactivity to at least one aeroallergen by elevated serum IgE.
Record weight and baseline plasma IgE of at least 30 IU/mL.
Document at least 2 severe exacerbations requiring oral corticosteroids or at least 1 hospitalization within the previous year.
Document 3 months of inadequate control despite medium- to high-dose ICS and LABA therapy and the planned add-on use of Xolair.

Documentation Required

Asthma Response Documentation

For asthma reauthorization, provide chart notes showing continued benefit and confirm that Xolair is not being used as monotherapy.

Document at least one improvement: fewer emergency department visits or hospitalizations for exacerbations; improved ability to exercise, function at school or work, or sleep; or reduced rescue-medication or oral-corticosteroid use.

Documentation Required

Food Allergy Clinical Documentation

For initial IgE-mediated food-allergy authorization, submit records confirming the allergic diagnosis, testing, dosing inputs, and required allergen-avoidance plan.

Member must be at least 1 year old and treatment must be prescribed by or in consultation with an allergist or immunologist.
Document a clinical history of allergic reactions and a positive skin-prick test or positive serum IgE.
Record weight in kilograms and baseline serum IgE in IU/mL.
Provider must attest that Xolair will be used with food-allergen avoidance and not with Palforzia.

Documentation Required

Food Allergy Response Documentation

For food-allergy reauthorization, document continued allergen avoidance and clinical benefit from Xolair.

Provider must attest that food-allergen avoidance will continue.
Chart notes must show clinical benefit and no anaphylaxis requiring advanced medical care.

Denial Risk

CRSwNP Criteria Not Met

CRSwNP is not medically necessary when the initial or continuation requirements are not met. Requests may be denied for failure to satisfy age, specialist, diagnostic, treatment, dosing, or response criteria.

Initial denial conditions include age under 18; no allergist, immunologist, or ENT involvement; fewer than 2 qualifying symptoms for at least 12 weeks; or no documented bilateral polyps.
Denial may result from missing weight or baseline IgE, failure to complete the required intranasal corticosteroid and saline trial with surgery or systemic corticosteroid history, lack of concurrent intranasal corticosteroid use, or use with another biologic.
Reauthorization may be denied without documented improvement in postnasal drip, polyp size, or nasal congestion, or without continued add-on intranasal corticosteroid therapy.

Denial Risk

CSU Criteria Not Met

CSU requests may be denied when the member does not meet the age, diagnosis, duration, severity, specialist, antihistamine-failure, or continuation requirements.

Initial denial conditions include age under 12; no qualifying allergist, dermatologist, or immunologist involvement; or no documented moderate-to-severe CSU with wheals or angioedema for more than 6 weeks.
Denial may result from failure to document a 14-day trial of a second-generation H1 antihistamine at 2–4 times the FDA-approved dosage or failure to continue that antihistamine with Xolair.
Reauthorization may be denied without chart-note evidence of positive clinical response, such as reduced itch severity or hive count.

Denial Risk

Asthma Criteria Not Met

Asthma requests may be denied when required age, specialist, allergy-testing, IgE, exacerbation, conventional-therapy, add-on, or response criteria are not documented.

Initial denial conditions include age under 6; no allergist, immunologist, or pulmonologist involvement; or no qualifying perennial aeroallergen testing or elevated serum IgE reactivity.
Denial may result from missing weight, baseline plasma IgE below 30 IU/mL, fewer than 2 OCS-treated exacerbations or 1 hospitalization in the prior year, or inadequate documentation of 3 months of medium- to high-dose ICS/LABA failure.
Xolair must not be used as monotherapy or with another asthma biologic; reauthorization requires documented clinical improvement, including reduced acute-care use, improved function or sleep, or reduced rescue medication or OCS use.

Denial Risk

Food Allergy Criteria Not Met

Food-allergy requests may be denied when the diagnosis, testing, dosing inputs, allergist or immunologist involvement, allergen-avoidance, or therapy requirements are not met.

Initial denial conditions include age under 1; no clinical history of IgE-mediated allergic reactions; or no positive skin-prick test or serum IgE.
Denial may result from missing weight or baseline serum IgE, failure to attest to food-allergen avoidance, or planned use with Palforzia.
Reauthorization requires continued allergen avoidance, documented clinical benefit, and no anaphylaxis requiring advanced medical care.

Denial Risk

Unlisted Indication

Xolair is not medically necessary for conditions or indications not listed in this policy. For another indication, the provider should refer to the applicable Off-Label policy for review.

Listed indications are CRSwNP, CSU, allergic asthma, and IgE-mediated food allergy.
An unlisted indication does not qualify for coverage under this policy.

Present for more than 6 weeks

IgE-mediated food allergy definition

ConditionIgE-mediated food allergy

Clinical confirmationHistory of allergic reactions

Supporting testingPositive skin-prick test or positive serum IgE testing

Facial pain or pressure.

Bilateral nasal polyps are documented by direct examination, endoscopy, or sinus CT scan.

Weight and baseline serum IgE are documented.

Symptoms persist after at least a 4-week intranasal corticosteroid plus nasal saline trial.

ONE of the following

Prior sinonasal surgery.
Systemic corticosteroids.

Medication is used as add-on maintenance treatment with an intranasal corticosteroid.

Medication is not used with another biologic therapy for CRSwNP.75-600 mg subcutaneously every 2 or 4 weeks

CSU Initial Criteria

CSU initial authorization requires ALL listed clinical criteria.

ALL listed clinical criteria

Member is at least 12 years of age.
Medication is prescribed by or under the recommendation of an allergist, dermatologist, or immunologist.
Member has moderate-to-severe chronic spontaneous urticaria with wheals, angioedema, or both present for more than 6 weeks.
Member has failed a second-generation H1 antihistamine at 2 to 4 times the FDA-approved dosage for 14 days.
Member will continue the second-generation H1 antihistamine with Xolair.150 or 300 mg subcutaneously every 4 weeks

Asthma Initial Criteria

Asthma initial authorization requires ALL listed clinical criteria.

ALL listed clinical criteria

Member is at least 6 years of age.
Medication is prescribed by or in consultation with an allergist, immunologist, or pulmonologist.
Qualifying allergy testing
- Positive skin testing for a perennial aeroallergen.
- Reactivity to at least one aeroallergen documented by elevated serum IgE.
Weight is documented and baseline plasma IgE is at least 30 IU/mL.>= 30 IU/mL
Qualifying severe exacerbations within the last year
- At least two requiring oral corticosteroids.
- At least one requiring hospitalization.
Asthma remains inadequately controlled after 3 months of medium- to high-dose inhaled corticosteroid and long-acting beta-2 agonist therapy.
Medication is used as add-on maintenance treatment.
Medication is not used with another biologic for asthma.75-375 mg subcutaneously every 2 or 4 weeks

Food Allergy Initial Criteria

Food allergy initial authorization requires ALL listed clinical criteria.

ALL listed clinical criteria

Member is at least 1 year of age.
Medication is prescribed by or in consultation with an allergist or immunologist.
IgE-mediated food allergy is confirmed by a clinical history of allergic reactions.
Positive skin-prick or serum IgE testing is documented.
Weight and baseline serum IgE are documented.
Provider attests that medication will be used with food allergen avoidance.
Medication will not be used with Palforzia.75-600 mg subcutaneously every 2 or 4 weeks

Provide chart notes supporting a positive clinical response, including reduced itch severity or hive count.12 additional months

Asthma Continuation Criteria

Asthma reauthorization requires ALL of the following.

ALL of the following

Do not use Xolair as monotherapy for asthma.
At least ONE documented improvement
- Reduced emergency department visits or hospitalizations due to asthma exacerbations.
- Improved functional ability, including exercise, school or work function, or quality of sleep.
- Reduced rescue medication or oral corticosteroid use.12 additional months

Food Allergy Continuation Criteria

Food allergy reauthorization requires ALL of the following.

ALL of the following

Continue food allergen avoidance.
Document clinical benefit and that the member has not experienced anaphylaxis requiring advanced medical care.12 additional months

Xolair dosing for asthma

Dose range75 mg to 375 mg

Route and frequencySubcutaneous injection every 2 or 4 weeks

Dose determinationBased on serum total IgE measured before treatment and body weight; use the package-insert dose determination chart

Xolair dosing for IgE-mediated food allergy

Dose range75 mg to 600 mg

Route and frequencySubcutaneously every 2 or 4 weeks

Dose determinationBased on serum total IgE measured before treatment and body weight; use the package-insert dose determination chart