Summary
Effective 2026-12-01, UnitedHealthcare Community Plan of New Mexico Medicaid revised its omalizumab medical policy: the title changed from Xolair to Omalizumab, the policy now covers Omlyclo (omalizumab-igec), Xolair, and any FDA-approved and launched omalizumab biosimilar (biosimilars not named are non-preferred until reviewed by UnitedHealthcare), HCPCS code Q5154 was added, and self-administered omalizumab is obtained under the pharmacy benefit rather than the medical benefit. Billing teams should update charge entry and product references so omalizumab claims for these members use the correct benefit and product codes.
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What to do
Action · 3 steps
01By 2026-12-01: Billing team, update charge entry and the omalizumab product list for New Mexico Medicaid members so that administered omalizumab (including Omlyclo, Xolair, and named or unnamed biosimilars) is billed under the medical benefit with the correct HCPCS code, adding Q5154 where applicable.
02Route self-administered omalizumab for these members to the pharmacy benefit.
03Providers and front desk staff should be told which product is being administered and where it is billed, and claims for non-preferred biosimilars should be reviewed against the policy before submission.
Codes mentioned
Q5154
Original notice
Omalizumab
uhcprovider.com · Always check the source before changing claims.
Related changes
See all UnitedHealthcare changes →OmalizumabMediumEffective Dec 1, 2026 · Medical Benefit Drug PolicyOmalizumabMediumEffective Dec 1, 2026 · Medical Benefit Drug PolicyOmalizumabMediumEffective Dec 1, 2026 · Medical Benefit Drug PolicyOmalizumabMediumEffective Dec 1, 2026 · Medical Benefit Drug PolicyBrowse every UnitedHealthcare change in the policy list