Omalizumab

This policy covers the use of omalizumab (Xolair) as an add‑on biologic for FDA‑approved and certain off‑label IgE‑mediated conditions, including moderate‑to‑severe allergic asthma (age ≥6), chronic spontaneous urticaria (age ≥12), chronic rhinosinusitis with nasal polyps (age ≥18), and IgE‑mediated food allergy (age ≥1). Coverage is contingent on specific clinical criteria (e.g., ≥3 months of controller therapy and uncontrolled asthma, baseline total IgE >30 IU/mL, body weight ≤150 kg, documented perennial aeroallergen sensitization), specialist prescribing for asthma, no concomitant antiasthmatic monoclonal antibody use, initial doses given in a monitored setting when indicated, and adherence to member benefit plan limits and off‑label evidence requirements.

"Coverage, exclusions, and any dollar caps or limitations are determined by the member's benefit plan, summary plan description, or contract; members and providers must consult that plan to determin..."