Medicare: Part B step therapy prior authorization requirements

Last updated: October 28, 2022

Effective for dates of service starting Jan. 1, 2023, we will require prior authorization for medications included in the UnitedHealthcare® Medicare Advantage Part B step therapy program. You’ll find the latest information in the Medicare Part B Step Therapy Programs Policy.

View the list of medications requiring prior authorization.

Step therapy requirements

Step therapy requirements do not apply for members who are already being treated with medications/medical devices on the list. Step therapy requirements for a non-preferred Part B step therapy drug are only applied if the member is newly starting therapy, meaning that they have not received the non-preferred drug in the last 365 days.

Step therapy prior authorization process

The prior authorization process evaluates whether the drug is appropriate for the individual member, taking into account:

• Applicable Medicare guidance
• Dosage recommendation from the FDA-approved labeling
• Terms of the member’s benefit plan
• Trial and failure of preferred products
• The member’s treatment history

Use the Prior Authorization and Notification tool to check prior authorization requirements, submit new medical prior authorizations and more. 

Simply, go to UHCprovider.com and sign in with your One Healthcare ID, then go to "Prior authorization" in the menu.

Determination and review timeline

We will complete prior authorizations, or preservice coverage determinations, for Part B drugs within 72 hours for standard requests or 24 hours for expedited requests. Notifications of the case determination, including appeal rights when applicable, will be provided within the required time frame.

We’ll issue a denial decision if we don’t receive sufficient clinical information to complete the review. To prevent denials due to a lack of information, please submit all clinical information when you submit a Part B drug prior authorization request.

Eligible members

Step therapy prior authorizations apply to UnitedHealthcare Medicare Advantage plans, including UnitedHealthcare Dual Complete®, Peoples Health and Preferred Care Partners plans of Florida.

California Medicare Advantage Plans are no longer excluded from the step therapy program. The Part B Step Therapy Program applies to members in these plans.

Requesting prior authorization for Part B drugs subject to step therapy should follow standard medical authorization practices, including within plans that have delegated utilization management operations to medical groups and/or independent practice associations (IPAs). Please submit authorization requests according to the plan protocols.

Excluded Plans

Step therapy requirements don’t apply to members in these plans:

Questions?

For questions related to the step therapy program and the corresponding policy, call the Provider Services number on the member’s health care ID card.

For questions about prior authorizations, call 888-397-8129.

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