omalizumab — Blue Cross Blue Shield of Montana

Initial criteria

• Pretreatment IgE 30–1850 IU/mL AND weight 10–150 kg
• Confirmed IgE-mediated food allergy by diagnostic testing (skin prick, serum specific IgE, or oral food challenge)
• Requested agent not used for emergency allergic reaction or anaphylaxis
• Patient will avoid known food allergens while treated with drug