Xolair — Medica

Initial criteria

• Patient is ≥ 1 year of age
• Baseline IgE level ≥ 30 IU/mL
• Positive skin prick or in vitro IgE test to one or more foods
• History of allergic reaction to a food meeting ALL: (a) systemic allergic reaction signs/symptoms (e.g., hives, swelling, wheezing, hypotension, GI symptoms); AND (b) occurred within a short period after ingestion; AND (c) significant enough to require prescription for epinephrine self-administered injectable/nasal product
• Patient has been prescribed an epinephrine self-administered injectable or nasal product
• Xolair will be used in conjunction with a food allergen-avoidant diet
• Medication prescribed by or in consultation with an allergist or immunologist

Approval duration

1 year