Summary
UnitedHealthcare's Kentucky Medicaid medical policy for omalizumab was revised to refer to all omalizumab products generically, listing Omlyclo (omalizumab-igec), Xolair, and any FDA-approved and launched biosimilar not named (which is treated as non-preferred until reviewed). HCPCS code Q5154 was added, and the policy clarifies that self-administered subcutaneous omalizumab is obtained under the pharmacy benefit rather than the medical benefit. The revised policy is effective 2026-12-01.
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What to do
Action · 3 steps
01By 2026-12-01: Billing team should update charge entry and the fee schedule so that Q5154 is available for omalizumab biosimilar administration claims for Kentucky Medicaid members, and confirm that claims for self-administered omalizumab are routed to the pharmacy benefit instead of being billed on the medical side.
02Providers and front desk staff should be told that Omlyclo and any unnamed FDA-approved biosimilar are considered non-preferred until UnitedHealthcare reviews them, so the team can check with the payer before scheduling those products.
03Review prior authorization requirements for these members in the prior auth tracker, and watch for the payer's next notice on biosimilar review.
Codes mentioned
Q5154
Original notice
Omalizumab
uhcprovider.com · Always check the source before changing claims.
Related changes
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