Drug IndexXolair (omalizumab)



Billing

Code: J2357

Description: Omalizumab injection

Unit: 5 MG

Payment: $39.459

Pay quarter: Q1 2024


Covered in Part D: Yes

Avg tier level: 4


Drug Cost

Calculate drug cost and reimbursement


Total WAC:

$1,282.21

Total Reimbursement:

$1,183.77

(ASP: $1,116.76, Margin: $67.01)

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# Units to bill:

30

Dosage & Frequency

Asthma

Dose and frequency is determined by serum total IgE level (IU/mL) and body weight (kg)

For patients aged 12 years or older
Pre-treatment Serum IgE (IU/mL)Body Weight (kg)
30-60>60-70>70-90>90-150
≥30-100150mg q 4 weeks150mg q 4 weeks150mg q 4 weeks300mg q 4 weeks
>100-200300mg q 4 weeks300mg q 4 weeks300mg q 4 weeks225mg q 2 weeks
>200-300300mg q 4 weeks225mg q 2 weeks225mg q 2 weeks300mg q 2 weeks
>300-400225mg q 2 weeks225mg q 2 weeks300mg q 2 weeks
>400-500300mg q 2 weeks300mg q 2 weeks375mg q 2 weeks
>500-600300mg q 2 weeks375mg q 2 weeks
>600-700375mg q 2 weeks


For patients aged 6-11 years

Nasal Polyps

Dose and frequency is determined by serum total IgE level (IU/mL) and body weight (kg)

Pre-treatment Serum IgE (IU/mL)Body Weight (kg)
>30-40>40-50>50-60>60-70>70-80>80-90>90-125>125-150
30-10075mg q 4 weeks150mg q 4 weeks150mg q 4 weeks150mg q 4 weeks150mg q 4 weeks150mg q 4 weeks300mg q 4 weeks300mg q 4 weeks
>100-200150mg q 4 weeks300mg q 4 weeks300mg q 4 weeks300mg q 4 weeks300mg q 4 weeks300mg q 4 weeks450mg q 4 weeks600mg q 4 weeks
>200-300225mg q 4 weeks300mg q 4 weeks300mg q 4 weeks450mg q 4 weeks450mg q 4 weeks450mg q 4 weeks600mg q 4 weeks375mg q 2 weeks
>300-400300mg q 4 weeks450mg q 4 weeks450mg q 4 weeks450mg q 4 weeks600mg q 4 weeks600mg q 4 weeks450mg q 2 weeks525mg q 2 weeks
>400-500450mg q 4 weeks450mg q 4 weeks600mg q 4 weeks600mg q 4 weeks375mg q 2 weeks375mg q 2 weeks525mg q 2 weeks600mg q 2 weeks
>500-600450mg q 4 weeks600mg q 4 weeks600mg q 4 weeks375mg q 2 weeks450mg q 2 weeks450mg q 2 weeks600mg q 2 weeks
>600-700450mg q 4 weeks600mg q 4 weeks375mg q 2 weeks450mg q 2 weeks450mg q 2 weeks525mg q 2 weeks
>700-800300mg q 2 weeks375mg q 2 weeks450mg q 2 weeks450mg q 2 weeks525mg q 2 weeks600mg q 2 weeks
>800-900300mg q 2 weeks375mg q 2 weeks450mg q 2 weeks525mg q 2 weeks600mg q 2 weeks
>900-1000375mg q 2 weeks450mg q 2 weeks525mg q 2 weeks600mg q 2 weeks
>1000-1100375mg q 2 weeks450mg q 2 weeks600mg q 2 weeks
>1100-1200450mg q 2 weeks525mg q 2 weeks600mg q 2 weeks
>1200-1300450mg q 2 weeks525mg q 2 weeks
>1300-1500525mg q 2 weeks600mg q 2 weeks


Chronic Idiopathic Urticaria (CIU)

• 150mg or 300mg SQ every 4 weeks


Billable NDCs

50242-0040-62

Xolair (GENENTECH, INC.)

150 MG


50242-0214-01

Xolair (GENENTECH, INC.)

75 MG


50242-0215-01

Xolair (GENENTECH, INC.)

150 MG



Prior Authorization

Aetna

United Healthcare

Anthem

Cigna


Resources

Drug Enrollment Form

Website