ModifiedColorado Rocky Mountain Health PlansPolicy 2025 P 1358-7
Xolair® (omalizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new
Prior authorization/notification policy for Xolair (omalizumab) prefilled syringe and autoinjector formulations for self-administered subcutaneous use across UnitedHealthcare commercial plans; defines initial and reauthorization clinical criteria for asthma, chronic spontaneous urticaria, chronic rhinosinusitis with nasal polyps, and IgE-mediated food allergy, plus exclusions and administrative notes.
Policy Summary
PayerColorado Rocky Mountain Health Plans
PolicyXolair® (omalizumab) - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new
Policy CodePolicy 2025 P 1358-7
Change TypeAnnual review; added food allergy indication; biologic combination updates
Effective DateJul 1, 2025
Next Review Date
Key ActionPrior authorization/notification is required for Xolair prefills for self-administered subcutaneous use; authorizations may be granted if indication-specific initial authorization or reauthorization criteria are met and will be issued for 12 months.
SourceLink
POLICY UPDATE CHANGES
Effective date set to 7/1/2025 and program applies to prefilled syringe and autoinjector formulations.
Added criteria for new indication, IgE-mediated food allergy (4/2024).
Annual reviews with updates to list of agents not to be used in combination with Xolair (added Tezspire).
4/2025 annual review documented; no changes to coverage criteria.
4Covered Indications (Asthma; CSU; Nasal Polyps; IgE-mediated Food Allergy)
12 mo