Xolair — Cigna

Asthma

Initial criteria

Patient has a baseline positive skin test or in vitro test for allergen-specific immunoglobulin E (IgE) for one or more perennial and/or seasonal aeroallergens; AND
Patient has received at least 3 consecutive months of combination therapy with BOTH of the following: a) an inhaled corticosteroid; AND b) at least one additional asthma controller or maintenance medication; AND
Patient has asthma that is uncontrolled or was uncontrolled at baseline as defined by ONE of the following: a) two or more asthma exacerbations requiring systemic corticosteroids in the previous year; OR b) one or more exacerbations requiring hospitalization, emergency department, or urgent care visit in the previous year; OR c) FEV₁ < 80% predicted; OR d) FEV₁/FVC < 0.80; OR e) asthma worsens upon tapering of oral corticosteroids; AND
The medication is prescribed by or in consultation with an allergist, immunologist, or pulmonologist.

Patient has already received at least 4 months of therapy with Xolair; AND
Patient continues to receive therapy with one inhaled corticosteroid or one inhaled corticosteroid-containing combination inhaler; AND
Patient has responded to therapy as determined by the prescriber (e.g., decreased exacerbations, symptoms, hospitalizations, rescue use, or improved lung function).

initial 6 months; reauth 1 year