Xolair® (omalizumab) is indicated for use in patients who meet all the following criteria:

• greater than or equal to 12 years of age;
• moderate-to-severe persistent asthma in those who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids;
• baseline IgE titre greater than or equal to 30 IU/mL;
• baseline FEV 1 less than 80% of predicted; and
• does not require oral steroids for maintenance therapy.

The recommended dosage of omalizumab is 150 mg to 375 mg subcutaneous every two to four weeks based on body weight and pre-treatment serum total IgE level.  Limit injections to not more than 150 mg/site.

Report 90799 for omalizumab.  When reporting unlisted code 90799, please provide a complete description of the service by printing the drug name and dosage in the narrative field of the electronic or paper claim form.

The use of omalizumab for any indication not listed on this policy is considered experimental/investigational, and therefore, not covered.  A participating, preferred, or network provider can bill the member for the denied service.

Coverage for omalizumab is determined according to individual or group customer benefits.  Omalizumab is not reimbursable under the prescription drug benefit.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious life-threatening condition and when medically necessary and appropriate for the patient’s condition.

PRN References

12/2003, Omalizumab (Xolair®) coverage guidelines

Genentech, Xolair® (omalizumab) Package Insert. Genentech, Inc.; San Francisco, CA

Omalizumab, A Recombinant Humanized Anti-IgE Antibody, Reduces Asthma-related Emergency Room Visits and Hospitalizations in Patients with Allergic Asthma. Journal Allergy Clinical Immunology, Vol. 111, No. 1, 01/2003

Omalizumab Improves Asthma-related Quality of Life in Patients with Severe Allergic Asthma. Journal Allergy Clinical Immunology, Vol. 111, No. 2, 02/2003