omalizumab — Blue Cross Blue Shield of Montana

Initial criteria

• Prescriber states patient has been treated with requested agent within past 90 days and is at risk if therapy is changed OR all following:
• Patient age 6 to <12 years: pretreatment IgE 30–1300 IU/mL AND weight 20–150 kg OR patient age ≥12 years: pretreatment IgE 30–700 IU/mL AND weight 30–150 kg
• Allergic asthma confirmed by positive skin or in vitro reactivity test to perennial aeroallergen
• History of uncontrolled asthma despite control therapy shown by one of: ≥2 courses systemic corticosteroids in past 12 months; serious exacerbations requiring hospitalization/mechanical ventilation/ER visit within past 12 months; controlled asthma worsens when corticosteroids tapered; or baseline FEV1 <80% predicted
• Patient currently treated with maximally tolerated inhaled corticosteroid for ≥3 months and adherent for ≥90 days within past 120 days OR has intolerance/contraindication to all inhaled corticosteroids
• Patient currently treated for ≥3 months and adherent for ≥90 days within past 120 days with one of: LABA, LAMA, LTRA, or theophylline OR has intolerance/contraindication to these agents
• Patient will continue asthma control therapy in combination with requested agent
• Requested dose based on pretreatment serum IgE and body weight per FDA labeling and ≤375 mg every 2 weeks
• Patient age within FDA labeling or supported compendia use