Xolair — Cigna

Initial criteria

• Patient age ≥ 12 years; AND
• Patient has/had urticaria > 6 weeks with symptoms > 3 days per week despite daily non-sedating H₁ antihistamine therapy titrated up to 4× standard FDA-approved dose; AND
• Medication is prescribed by or in consultation with an allergist, immunologist, or dermatologist.

Reauthorization criteria

• Patient has already received ≥ 6 months of therapy with Xolair; AND
• Patient has experienced beneficial clinical response as defined by ONE of the following: decreased itch severity; OR decreased number of hives; OR decreased size of hives.

Approval duration

initial 6 months; reauth 1 year