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

Initial criteria

• Diagnosis of chronic rhinosinusitis with nasal polyps
• Patient age ≥ 18 years
• Prescribed by or in consultation with an allergist, immunologist, or otolaryngologist
• Patient is concurrently treated with intranasal corticosteroids OR has contraindication to intranasal corticosteroids
• Patient will not be concurrently treated with an alternative biologic for nasal polyps

Reauthorization criteria

• Diagnosis of chronic rhinosinusitis with nasal polyps
• Patient age ≥ 18 years
• Prescribed by or in consultation with an allergist, immunologist, or otolaryngologist
• Patient is concurrently treated with intranasal corticosteroids OR has contraindication to intranasal corticosteroids
• Therapeutic response demonstrated by ≥ 1 of the following: adequate sinus ventilation and drainage, control of mucosal inflammation and edema, or reduction in exacerbations
• Patient will not be concurrently treated with an alternative biologic for nasal polyps

Approval duration

initial 6 months; reauth 12 months