Medicare AdvantagePrior AuthHigh impact
Xolair® (omalizumab) (Revised)
Humana·Allergy & Immunology, Pulmonology, ENT (Ear, Nose & Throat) +1 more·Medicare Advantage
Effective date
Jan 1, 2024
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Xolair (omalizumab) effective January 1, 2024, with the most recent revision dated March 25, 2026. The policy covers four indications: chronic idiopathic urticaria (age 12+), moderate to severe persistent asthma (age 6+), nasal polyps (age 18+), and IgE-mediated food allergy (age 1+). All Xolair prescriptions require prior authorization with specific clinical criteria that must be met before approval.
Action Required
By immediately and continuing through all claims submission: Billing team must implement prior authorization requirements for ALL Xolair (omalizumab) claims in the billing system. Specifically: (1) Configure system to require prior auth for Xolair subcutaneous solution, syringe, and auto-injector formulations; (2) For chronic idiopathic urticaria claims, verify documentation shows patient age 12+, diagnosis of CIU, 2+ weeks of H1 antihistamine therapy, and concurrent H1 antihistamine continuation; (3) For asthma claims, verify patient age 6+, moderate-to-severe persistent asthma diagnosis, positive skin/blood test for specific IgE to perennial aeroallergen, baseline serum IgE ≥30 IU/mL, and inadequate control despite inhaled corticosteroids; (4) For nasal polyps claims, verify patient age 18+, CRSwNP diagnosis, failure of maximum tolerated intranasal corticosteroid therapy, and concurrent intranasal corticosteroid use; (5) For food allergy claims, verify patient age 1+, IgE-mediated food allergy diagnosis, and food allergen avoidance compliance. Billing team must route all prescriptions through prior authorization process before claim submission. Providers must ensure clinical documentation supports all criteria. Failure to obtain prior authorization will result in claim denials.