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Medical Policy Revision: Omalizumab Xolair

Effective January 16, 2017, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims for Xolair®.

Our revised medical policy, Omalizumab (Xolair), identifies when use of Xolair would be considered medically necessary or investigational. We encourage you to review this policy in our Medical Policy Manual.

Based on the guidelines of our revised medical policy, Omalizumab (Xolair):

  • Claims that include HCPCS code J2357 for services provided on and after January 16, 2017 will pend, regardless of patient age or submitted diagnosis codes(s), while we request information to help us determine if the use of this drug is to be considered medically necessary or investigational.
  • Claims that include HCPCS code C9473 for services provided on and after January 16, 2017 to patients 6 years of age and older, based on the submitted diagnosis code(s), may pend while we request information to help us determine if the use of this drug is to be considered medically necessary or investigational.

 

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after January 16, 2017.

Xolair® is a registered trademark of Genentech USA, Inc. and Novartis Pharmaceuticals Corporation.

Published on: October 18, 2016, 13:43 p.m. ET
Last updated on: November 25, 2020, 00:33 a.m. ET