Xolair (omalizumab) pre-filled syringe for self-administration — Point32Health

Initial criteria

• Diagnosis of moderate to severe chronic idiopathic urticaria present ≥ 6 weeks
• Patient age ≥ 12 years
• Prescribed by or in consultation with an allergist, dermatologist, or immunologist
• Patient remains symptomatic despite treatment with a second-generation H1 antihistamine (e.g., cetirizine, fexofenadine, levocetirizine, loratadine) OR has contraindication to second-generation H1 antihistamines

Reauthorization criteria

• Diagnosis of moderate to severe chronic idiopathic urticaria
• Patient age ≥ 12 years
• Prescribed by or in consultation with an allergist, dermatologist, or immunologist
• Therapeutic response demonstrated by ≥ 1 of the following: reduced itching, reduction in number and/or size of hives

Approval duration

initial 6 months; reauth 12 months