UnitedHealthcare Implements Step Therapy Prior Authorization For Medicare Part B

UnitedHealthcare announced that it will require prior authorization on medications under the Medicare Advantage Part B Step Therapy Program starting Jan. 1, 2025. It has lined up an effective move to manage the utilization of targeted high-cost drugs and ensure that patients try the preferred treatments before using the costlier alternatives.

This new policy rules that step therapy requirements will be only applicable to new member enrollment. However, the existing member definition applies to individuals who had a claim within 365 days on a non-preferred drug. Members with clinical documentation showing continued use of the drug are not bound by this rule.

The UnitedHealthcare Medicare Advantage, UnitedHealthcare Dual Complete, Peoples Health, and Preferred Care Partners of Florida plans would be affected. A complete listing of denied plans and medications is available in the official Medicare Part B Step Therapy Program Policy.

There should be prior authorization requests through standard protocols that providers will submit. This includes plans where utilization management has been delegated to medical groups or IPAs. Providers can easily access the prior authorization process via UnitedHealthcare Provider Portal using their One Healthcare ID on a form that is submitted under categories like “Specialty Pharmacy” or “Oncology.” All clinical information about the patient must be submitted on all claims to avoid delays or denials.

UnitedHealthcare assures standard processing for prior authorization requests for Part B drugs within 72 hours and expedited ones within 24 hours. Providers will be notified of the decision and of any rights they may have to appeal.

If you seek more information, visit UnitedHealthcare Provider Portal. You will find UnitedHealthcare online 24/7 or connect via telephone at 888-397-8129.

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

This shift represents the latest steps in optimizing medication use on the part of UnitedHealthcare under Medicare Part B toward efficiency without compromising on high standards of patient care.