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Xolair (omalizumab)


Billing

Code: J2357

Description: Omalizumab injection

Unit: 5 mg

Payment: $39.383

Pay quarter: Q3 2023


Medicare history

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
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

Calculate drug reimbursement


Total Reimbursement:

$1,252.38

(ASP: $1,181.49, Margin: $70.89)


Code:

J2357

# Units to bill:

30

Prior 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:

Aetna

United Healthcare

Anthem

Cigna


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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