Health Net
Xolair (omalizumab)
Drugs for the Lungs : Drugs for Asthma/COPD
  • Asthma (injectable):
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    # of exacerbations in prior year: >= 2
    Additional controller failure requirement: 1
    Diagnosis Type: Moderate to Severe
    Evidence of Asthma Indicators: Pre-treatment serum IgE (IU/mL) >= 30 in age >= 6
    Patient Weight Required: No
    Must Be Compliant with Therapy: No
    Non-smoker or Will Begin Smoking Cessation Efforts: No
    Symptoms Are Not Adequately Controlled: No
    Exacerbation Requiring Treatment with Systemic Corticosteroid: Optional
    Use in Combination with Other Injectable Asthma Product: No
    Positive Skin Test or In Vitro Test (RAST) to a Perennial Aeroallergen: Yes
    IgE Level Required: Yes
    Administered in a Controlled Healthcare Setting with Access to Emergency Medications: No
    Submission of Medical Records Required: Yes
    Exclusion Condition(s): 1 of Acute bronchospasm;Status asthmaticus
    Eosinophilic asthma phenotype: No
    Injectable ST Required: No

    Chronic Idiopathic Urticaria (CIU):
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Allergist;Dermatologist;Immunologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)

    Nasal Polyposis:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Allergist;Immunologist;Otolaryngologist (Ear, Nose, and Throat Specialist)
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

  • Step Therapy: Chronic Idiopathic Urticaria (CIU):
    ST Multiple Generics

    Nasal Polyposis:
    ST Generic and Brand

  • Prior Authorization: Asthma (injectable):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Chronic Idiopathic Urticaria (CIU):
    Documented Diagnosis: Yes
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Nasal Polyposis:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

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