Xolair (omalizumab)
Billing
Code: J2357
Description: Omalizumab injection
Unit: 5 mg
Payment: $39.383
Pay quarter: Q3 2023
Dosage and 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
For patients aged 6-11 years
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 | |
≥30-100 | 150mg q 4 weeks | 150mg q 4 weeks | 150mg q 4 weeks | 300mg q 4 weeks |
>100-200 | 300mg q 4 weeks | 300mg q 4 weeks | 300mg q 4 weeks | 225mg q 2 weeks |
>200-300 | 300mg q 4 weeks | 225mg q 2 weeks | 225mg q 2 weeks | 300mg q 2 weeks |
>300-400 | 225mg q 2 weeks | 225mg q 2 weeks | 300mg q 2 weeks | |
>400-500 | 300mg q 2 weeks | 300mg q 2 weeks | 375mg q 2 weeks | |
>500-600 | 300mg q 2 weeks | 375mg q 2 weeks | ||
>600-700 | 375mg 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)
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 | |
30-100 | 75mg q 4 weeks | 150mg q 4 weeks | 150mg q 4 weeks | 150mg q 4 weeks | 150mg q 4 weeks | 150mg q 4 weeks | 300mg q 4 weeks | 300mg q 4 weeks |
>100-200 | 150mg q 4 weeks | 300mg q 4 weeks | 300mg q 4 weeks | 300mg q 4 weeks | 300mg q 4 weeks | 300mg q 4 weeks | 450mg q 4 weeks | 600mg q 4 weeks |
>200-300 | 225mg q 4 weeks | 300mg q 4 weeks | 300mg q 4 weeks | 450mg q 4 weeks | 450mg q 4 weeks | 450mg q 4 weeks | 600mg q 4 weeks | 375mg q 2 weeks |
>300-400 | 300mg q 4 weeks | 450mg q 4 weeks | 450mg q 4 weeks | 450mg q 4 weeks | 600mg q 4 weeks | 600mg q 4 weeks | 450mg q 2 weeks | 525mg q 2 weeks |
>400-500 | 450mg q 4 weeks | 450mg q 4 weeks | 600mg q 4 weeks | 600mg q 4 weeks | 375mg q 2 weeks | 375mg q 2 weeks | 525mg q 2 weeks | 600mg q 2 weeks |
>500-600 | 450mg q 4 weeks | 600mg q 4 weeks | 600mg q 4 weeks | 375mg q 2 weeks | 450mg q 2 weeks | 450mg q 2 weeks | 600mg q 2 weeks | |
>600-700 | 450mg q 4 weeks | 600mg q 4 weeks | 375mg q 2 weeks | 450mg q 2 weeks | 450mg q 2 weeks | 525mg q 2 weeks | ||
>700-800 | 300mg q 2 weeks | 375mg q 2 weeks | 450mg q 2 weeks | 450mg q 2 weeks | 525mg q 2 weeks | 600mg q 2 weeks | ||
>800-900 | 300mg q 2 weeks | 375mg q 2 weeks | 450mg q 2 weeks | 525mg q 2 weeks | 600mg q 2 weeks | |||
>900-1000 | 375mg q 2 weeks | 450mg q 2 weeks | 525mg q 2 weeks | 600mg q 2 weeks | ||||
>1000-1100 | 375mg q 2 weeks | 450mg q 2 weeks | 600mg q 2 weeks | |||||
>1100-1200 | 450mg q 2 weeks | 525mg q 2 weeks | 600mg q 2 weeks | |||||
>1200-1300 | 450mg q 2 weeks | 525mg q 2 weeks | ||||||
>1300-1500 | 525mg q 2 weeks | 600mg q 2 weeks |
Chronic Idiopathic Urticaria (CIU)
• 150mg or 300mg SQ every 4 weeks
• 150mg or 300mg SQ every 4 weeks
Calculate drug reimbursement
Total Reimbursement:
$1,252.38(ASP: $1,181.49, Margin: $70.89)
Code:
J2357# Units to bill:
30Prior Authorization
Prior auth criteria for Xolair may include but is not limited to:
1. Documentation of a positive skin test or in vitro IgE test to a perennial aeroallergen.
2. Patient has been diagnosed with moderate-to-severe persistent asthma not adequately controlled with inhaled corticosteroids and other controller medications.
3. Patient is 12 years of age or older.
4. Patient has an eosinophilic phenotype (blood eosinophil count ?300 cells/?L or ?150 cells/?L in the presence of low IgE) or an elevated serum IgE level (?30 IU/mL).
5. Patient has had a documented exacerbation (oral corticosteroid treatment or emergency department visit/hospitalization) due to asthma in the past 12 months.
6. Patient has not previously received Xolair therapy or, if the patient has, the patient has not had an adequate response to the therapy.
Insurance prior auth guidelines:
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
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