Medicare: Part B step therapy prior authorization requirements

Effective for dates of service starting Jan. 1, 2025, we will require prior authorization for medications included in the UnitedHealthcare® Medicare Advantage Part B Step Therapy Program. You’ll find the latest information, including excluded plans, in the Medicare Part B Step Therapy Program Policy.

View the list of medications included in the Part B Step Therapy Program. 

Step therapy requirements

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

Part B step therapy requirements do not apply for members who are already being treated with a non-preferred drug/product (existing utilizers) included in the Part B Step Therapy Program. For the purposes of this program, an existing utilizer means the member has a paid claim for the drug/product within the past 365 days or has clinical documentation of current use of the non-preferred drug/product.

Eligible members

Step therapy prior authorization 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 Program Policy.

Prior authorization requests 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.

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

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

To submit an online request for authorization simply go to UHCprovider.com and sign in with your One Healthcare ID. Click on “Prior Authorizations” and then select “Create a new prior authorization submission.” Select the appropriate request type in the dropdown menu (e.g., “Specialty Pharmacy” or “Oncology”).

Note: To prevent denials due to a lack of information, please submit all clinical information when you submit a Part B drug prior authorization request.

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.

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

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