Summary
Effective 2026-12-01, UnitedHealthcare's Community Plan of Tennessee Medicaid policy for omalizumab is retitled from Xolair to omalizumab and now covers Omlyclo (omalizumab-igec), Xolair, and any FDA-approved, launched omalizumab biosimilar not named in the policy, with unlisted biosimilars treated as non-preferred until UnitedHealthcare reviews them. Omalizumab for healthcare-professional-administered subcutaneous injection falls under this medical benefit policy, while self-administered omalizumab is obtained under the pharmacy benefit, and HCPCS code Q5154 has been added.
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What to do
Action · 3 steps
01By 2026-12-01: Billing team should add HCPCS Q5154 to the charge master and charge entry for omalizumab products administered in the office, and update the claim edits so omalizumab claims for Tennessee Medicaid members are billed with the correct product code.
02Providers and front desk staff should be told that only in-office healthcare-professional-administered omalizumab is billed under this medical benefit, while self-administered omalizumab must be routed to the pharmacy benefit.
03Billing team should update the payer-specific product reference in the practice's workflow so that Omlyclo, Xolair, and biosimilars are each recorded by their exact product name, and watch for UnitedHealthcare's review of unlisted biosimilars, since claims for products not yet reviewed will be treated as non-preferred.
Codes mentioned
Q5154
Original notice
Omalizumab
uhcprovider.com · Always check the source before changing claims.
Related changes
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