Xolair — Highmark
chronic rhinosinusitis with nasal polyps (CRSwNP)
Initial criteria
- age ≥ 18 years
- diagnosis of nasal polyps (ICD-10 J33.0, J33.1, J33.8, J33.9) with chronic rhinosinusitis
- Xolair will be add-on to nasal corticosteroid maintenance treatment
- prescriber attests member is appropriate candidate for self-administration, meeting ALL: (a) no history of anaphylaxis AND (b) will receive at least 3 doses of Xolair (syringe or vial) under healthcare provider guidance with no hypersensitivity reactions
- prescriber submits documentation of current weight AND pretreatment serum IgE
Reauthorization criteria
- prescriber submits documentation of current weight AND pretreatment serum IgE
- prescriber attests one of the following: (a) decrease in nasal polyp score OR (b) reduction in nasal congestion/obstruction severity score
- member continues using Xolair with nasal corticosteroid as add-on maintenance therapy