Medicare: Updated Part B step therapy prior authorization requirements

Starting Jan. 1, 2027, additional medications will be added to the UnitedHealthcare® Medicare Advantage Part B Step Therapy Program. Medications included in this program require prior authorization before coverage is approved. This process helps ensure members receive safe, effective and clinically appropriate care based on their individual health needs and established treatment guidelines.

Review the list of medications included in the Part B Step Therapy Program and refer to the Medicare Part B Step Therapy Programs Policy for the latest information.

Step therapy requirements

You may need to seek prior authorization for new UnitedHealthcare members so we can validate past utilization in the absence of UnitedHealthcare claims history.

Part B step therapy requirements don’t apply to members who are already being treated with a non-preferred drug/product included in the Part B Step Therapy Program. These individuals are known as existing utilizers, which means they’ve paid a claim for the drug/product within the past 365 days or have clinical documentation of current use of the non-preferred drug/product. 

Step therapy prior authorization process 

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

• Applicable Medicare coverage determination 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

How to submit and manage prior authorizations

• Sign in to the UnitedHealthcare Provider Portal with your One Healthcare ID
  •  If you don’t have a One Healthcare ID, register now
• From the left-hand tabs, select Prior Authorizations & Notifications
• To submit a new authorization request, select Create a new prior authorization submission
  • Select the appropriate request type from the dropdown menu

For training, view our Prior Authorization and Notification interactive guide.

Determination and review timeline

We’ll 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 requirements apply to UnitedHealthcare Medicare Advantage plans, including UnitedHealthcare Dual Complete®, Peoples Health and Preferred Care Partners plans of Florida. Specific plan exclusions are noted in the Medicare Part B Step Therapy Programs Policy.

Prior authorization requests for Part B drugs included in the Step Therapy Program should follow standard medical authorization practices, including within plans that have delegated utilization management operations to medical groups and/or independent practice associations. Please submit authorization requests according to the plan protocols.