omalizumab — Highmark

Initial criteria

• if request is for Xolair prefilled syringe: age ≥ 1 year; if request is for Xolair autoinjector: age ≥ 12 years
• prescribed by or in consultation with an allergist or immunologist
• diagnosis of food allergy (ICD-10 Z91.01) classified as IgE mediated confirmed by skin prick test or food-specific (sIgE) antibodies
• prescriber attests member had previous allergic reaction to food
• prescriber attests Xolair used for reduction of allergic reactions (type 1), including anaphylaxis
• prescriber attests Xolair used in conjunction with food allergen avoidance
• prescriber submits documentation of current weight AND pretreatment serum IgE
• prescriber attests member is appropriate candidate for self-administration meeting ALL: (a) no history of anaphylaxis to Xolair or other agents (except foods) AND (b) will receive ≥3 doses of Xolair under healthcare provider guidance with no hypersensitivity reactions AND (c) member has documented prescription for epinephrine