Xolair (omalizumab) — United Healthcare

Initial criteria

• EITHER: (a) Patient has been established on therapy with Xolair for nasal polyps under an active UnitedHealthcare medical benefit prior authorization AND Documentation of positive clinical response to Xolair therapy AND Patient is not receiving Xolair in combination with anti-interleukin 4 therapy, anti-interleukin 5 therapy, or TSLP inhibitor therapy
• OR: (b) Diagnosis of nasal polyps AND Patient has had inadequate response to nasal corticosteroids [e.g., fluticasone (Flonase), budesonide (Rhinocort), mometasone (Nasonex)] AND Patient continues current maintenance therapy AND Patient is not receiving Xolair in combination with anti-interleukin 4, anti-interleukin 5, or TSLP inhibitor therapy

Reauthorization criteria

• Documentation of positive clinical response to Xolair therapy AND Patient is not receiving Xolair in combination with anti-interleukin 4, anti-interleukin 5, or TSLP inhibitor therapy

Approval duration

12 months