CurrentUnitedHealthcarePolicy CSIND0033.06

Xolair® (Omalizumab) (for Indiana Only) – Community Plan Medical Benefit Drug Policy

State-specific UnitedHealthcare Community Plan medical benefit drug policy that applies only to Indiana members and references InterQual specialty Rx non-oncology omalizumab criteria to define medical necessity. Provides applicable HCPCS code and administrative instructions.

Policy Summary

PayerUnitedHealthcare

PolicyXolair® (Omalizumab) (for Indiana Only) – Community Plan Medical Benefit Drug Policy

Policy CodePolicy CSIND0033.06

Change TypeRoutine review; no content changes

Effective DateOct 1, 2025

Next Review Date

Key ActionProviders must refer to and document that the patient's condition meets the current InterQual CP: Specialty Rx Non-Oncology, Omalizumab (Xolair) criteria to support medical necessity for coverage.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

1Referenced HCPCS code(s)

IndianaGeographic scope

InterQualClinical criteria source

Coverage Summary

Coverage stance: covered with criteria. Medical necessity is determined by the InterQual guideline CP: Specialty Rx Non-Oncology, Omalizumab (Xolair). This is a state-specific UnitedHealthcare Community Plan medical benefit drug policy that applies only to Indiana. Effective date: October 1, 2025; Last review/effective: October 1, 2025.