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.
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.
Step therapy prior authorizations apply to UnitedHealthcare Medicare Advantage plans, including UnitedHealthcare Dual Complete®, Preferred Care Partners plans in Florida.
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
UnitedHealthcare Senior Care Options in Massachusetts
Employer Group Medicare Advantage
All group health maintenance organization (HMO) plans
Select group preferred provider organization (PPO) plans
Johnson & Johnson
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.
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.