Xolair — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of CSU/CIU with hives and itching >6 weeks
• If treated with medications known to worsen urticaria, prescriber reduced/discontinued or provided rationale why not appropriate
• One of: inadequate response to FDA-labeled maximum dose of one second-generation H1-antihistamine for ≥2 weeks and inadequate response or cannot tolerate 2× max dose; intolerance/hypersensitivity to one second-generation H1-antihistamine; or contraindication to all second-generation H1-antihistamines
• Requested dose within FDA labeling and ≤300 mg every 4 weeks