Anthem Blue Cross (HMO, PPO, EPO)
Xolair (omalizumab)
Drugs for the Lungs : Drugs for Asthma/COPD
  • 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
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Asthma (injectable):
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)
    History of corticosteroid use: >= 3 months
    Additional controller failure requirement: 1
    Diagnosis Type: Moderate to Severe
    Evidence of Asthma Indicators: 2 of FEV1 < 80% predicted;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: No
    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: No
    Eosinophilic asthma phenotype: No
    Injectable ST Required: No

    Chronic Idiopathic Urticaria (CIU):
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)

    Nasal Polyposis:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)

  • Available only through Specialty Pharmacy;
    For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click  HERE; Dosing Limit: See clinical criteria for details;
  • Step Therapy: ST Multiple Generics

  • PA Applies
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