Subject: Specialty Quantity Limit Xolair 2544-H P2023
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. The recommended
dosing parameters for all FDA-approved indications fall within
the standard limits. Coverage of an additional quantity may be
reviewed on a case-by-case basis upon request.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
FDA-recommended dosing
|
|
Xolair 150 mg vial
|
8 vials per 28 days
|
Asthma: 75 to 375 mg every 2 or 4 weeks.
Determine dose (mg) and dosing frequency
by serum total IgE (IU/mL) and body
weight.
Chronic spontaneous urticaria: 150 or 300
mg every 4 weeks. Dosing in CSU is not
dependent on serum IgE level or body
weight.
Chronic rhinosinusitis with nasal polyps
(CRSwNP): 75 mg to 600 mg every 2 or 4
weeks. Determine dose (mg) and dosing
frequency by serum total IgE (IU/mL) and
body weight.
|
|
Xolair 75 mg
single-dose
prefilled syringe
|
2 syringes
per 28 days
|
|
Xolair 150 mg
single-dose
prefilled syringe
|
8 syringes
per 28 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Xolair [package insert]. South San Francisco, CA: Genentech, Inc.; March 2023.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
August 13, 2023
