Medicare: Part B step therapy prior authorization requirements
Last modified: Jan. 2, 2024
Updated the link to the latest Medicare Part B Step Therapy Programs
Effective for dates of service starting Jan. 1, 2024, 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 Programs 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.
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.
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 our review of prior authorization or pre-service coverage determination requests for Part B drugs within 72 hours for standard requests or within 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 relevant clinical information when you submit a Part B drug prior authorization request.
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 Programs 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 prior authorization requests according to the applicable plan protocols.
Questions?
Chat with a live advocate 7 a.m.–7 p.m. CT from the UnitedHealthcare Provider Portal Contact Us page. You can also contact UnitedHealthcare Provider Services at 877-842-3210, TTY/RTT 711, 7 a.m.–5 p.m. CT, Monday–Friday.
For questions about prior authorizations, call 888-397-8129.
