Xolair autoinjector — Highmark

Initial criteria

• If the request is for Xolair prefilled syringe, the member is age ≥ 1 year
• If the request is for Xolair autoinjector, the member is age ≥ 12 years
• The prescriber submits documentation substantiating all of the following: current weight AND pretreatment serum IgE

Reauthorization criteria

• The prescriber attests that the member has experienced a positive clinical response to therapy
• The prescriber attests the member requires continuation of therapy
• The prescriber attests the member will continue food allergen avoidance

Approval duration

initial: 6 months; reauthorization: 12 months