Xolair (omalizumab) — United Healthcare

Initial criteria

• EITHER (a) Patient established on Xolair with positive clinical response AND used as add-on maintenance therapy with intranasal corticosteroids AND not used with anti-IL4, anti-IL5, or TSLP inhibitor
• OR (b) Diagnosis of nasal polyps AND ≥2 symptoms >12 weeks (nasal discharge, obstruction, facial pain/pressure/fullness, loss of smell) AND findings of polyps or mucosal changes on endoscopy or CT AND either (failure of intranasal corticosteroids + another therapy such as saline or antileukotriene, OR systemic corticosteroids in past 2 years, OR prior sinus surgery) AND used as add-on with intranasal corticosteroids AND not used with anti-IL4, anti-IL5, or TSLP inhibitor AND prescribed by allergist, immunologist, otolaryngologist, or pulmonologist

Reauthorization criteria

• Positive clinical response to Xolair AND continued use as add-on maintenance therapy with intranasal corticosteroids

Approval duration

12 months