Medicare: New required Part B step therapy prior authorizations

Effective for dates of service starting Jan. 1, 2022, prior authorization is required for new 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.

See the list of affected medications.

Step therapy requirements

These step therapy prior authorization requirements don’t apply to members being treated with medications or medical devices on the list before Jan. 1, 2022.

Prior authorization for a non-preferred drug is required if the member is new to therapy (has not been on the drug for the past 365 days) or if the patient is a new UnitedHealthcare member.

If the Medicare Advantage member has a prior UnitedHealthcare claim for a non-preferred Part B step therapy drug in the previous 365 days, you won’t need to submit a prior authorization request.

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

Determination and review timeline

Medicare Advantage Part B drug coverage determinations or prior authorization reviews are completed within 72 hours, or 24 hours for expedited requests. We’ll issue notifications, including appeal rights, within the required time frame.

We’ll issue a denial decision if we don’t receive clinical information to complete the review. To help avoid denial decisions 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®, Medica HealthCare and Preferred Care Partners plans in Florida.

Excluded members

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

  • Non-Employer Group Medicare Advantage
    • All UnitedHealthcare Medicare Advantage plans in California
    • Certain UnitedHealthcare Dual Complete plans in Arizona, New Jersey, Tennessee and Virginia
    • Erickson Advantage
    • UnitedHealthcare MedicareDirect (Private Fee-for-Service)
    • UnitedHealthcare Senior Care Options in Massachusetts
  • UnitedHealthcare Connected®
  • Employer Group Medicare Advantage
    • All group health maintenance organization (HMO) plans
    • Select group preferred provider organization (PPO) plans
      • Navistar
      • Johnson & Johnson
      • Bristol-Myers Squibb
      • Verizon
      • U.S. Government of the Virgin Islands (USGVI)

For members in UnitedHealthcare Medicare Advantage plans where a delegate manages utilization management and prior authorization requirements, you’ll continue to follow the delegate’s standard prior authorization process.

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, 8 a.m.–5 p.m. local time, Monday–Friday.

PCA-1-21-03201-PH-NEWS_09162021