Summary
Effective 2026-12-01, the Nebraska Medicaid (UnitedHealthcare Community Plan) medical benefit drug Maximum Dosage and Frequency policy was revised: the list of maximum allowed quantities and frequencies by HCPCS units was updated, Exdensur (depemokimab) and Spinraza (nusinersen) were added, HCPCS codes J2326 and J2361 were added, and the descriptions for Q5136 and Q5157 were revised. Claims for these drugs billed above the listed per-administration units or frequency limits will be subject to the plan's limits, so the practice should align dosing and unit entry with the updated list.
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What to do
Action · 3 steps
01Before 2026-12-01: Billing team should review the updated maximum allowed quantities and frequencies by HCPCS unit in the policy, particularly for Exdensur (depemokimab), Spinraza (nusinersen), J2326, J2361, Q5136 and Q5157, and update charge entry and unit calculations so claims for Nebraska Medicaid members reflect the revised limits.
02Providers and front desk staff should be told that doses above the listed maximum per administration or frequency may not be covered, and that body weight above 140 kg or body surface area above 2.71 m2 may allow higher units, documented in the medical record.
03Where claims exceed limits, the practice should confirm documentation supports the dose or seek plan authorization before administration, and appeal or resubmit with supporting clinical evidence if a claim is limited.
Codes mentioned
J2326J2361Q5136Q5157
Original notice
Maximum Dosage and Frequency
uhcprovider.com · Always check the source before changing claims.
Related changes
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