Xolair — Cigna

Initial criteria

• Patient age ≥ 1 year; AND
• Baseline immunoglobulin E (IgE) level ≥ 30 IU/mL prior to Xolair or other monoclonal antibody therapy; AND
• Patient has a positive skin prick test or positive in vitro test (blood test) for IgE to one or more foods; AND
• Prescriber confirms history of allergic reaction to a food with ALL of the following: a) signs/symptoms of a significant systemic allergic reaction; AND b) reaction occurred shortly after known ingestion; AND c) reaction significant enough to require prescription for epinephrine product; AND
• Patient has been prescribed an epinephrine self-administered injectable or nasal product; AND
• Prescriber confirms Xolair will be used in conjunction with a food allergen-avoidant diet; AND
• Medication prescribed by or in consultation with an allergist or immunologist.

Approval duration

1 year