Xolair

Covered Uses:	All FDA approved indications not otherwise excluded from Part D.
Exclusion Criteria:
Required Medical Information:	Baseline IgE must be greater than or equal to 30 IU/mL. The patient is currently receiving therapy with an inhaled steroid or oral steroid unless the patient should not receive steroids AND either 1. The dose of inhaled or systemic steroid must be reduced to help control adverse side effects and addition of Xolair is the only option that may achieve the needed dosage reduction OR 2. The patient has moderate to severe asthma defined as having had two or more ER visits for an asthma exacerbation AND/OR more than 2 courses of short pulse oral or parenteral corticosteroids for exacerbations within the previous 12 months.
Age Restrictions:	Coverage is provided for patients 12 years of age and older
Prescriber Restrictions:
Coverage Duration:	12 months
Other Criteria:	Coverage may be renewed in situations where treatment if providing clinical benefit as evidenced by a reduction in asthma exacerbations from baseline.

Last Modified on 12/20/2012