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.
Routine review; no content changes.
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.
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