Allergy
Pharmacy/Prescription Drugs

The patient is a female who is requesting for Xolair for urticaria. She has tried Claritin, Zyrtec, hydroxyzine and prednisone in the past. She has tried levocetirizine once a day per pharmacy fills. Clinic note indicates that patient has tried Zyrtec 40 milligrams (mg) once a day and 320 mg of Allegra. She has tried Xolair samples. The subject under review is the medical necessity for Xolair.

The health plan's determination is upheld.

No. Treatment with Xolair is not medically necessary. While the most recent note indicates that the patient is on Zyrtec 40 mg once a day and 320 mg of Allegra, the medical information does not indicate how long she has been on these doses of second generation antihistamines
Xolair is an immunoglobulin E (IgE) monoclonal antibody. The formulary alternatives Cetirizine (up to 40mg daily), levocetirizine (up to 20mg daily), Loratadine (up to 40 mg daily) or Fexofenadine (up to 720mg daily) are second generation antihistamines.
Per standard practice guidelines, first line treatment for chronic urticaria is high dose second generation antihistamines up to 4 times the normal doses. The patient has not yet shown adequate failure of first line treatments. Therefore, the treatment with Xolair is not medically necessary.