Medicare AdvantagePrior AuthMedium impact
Medicare Part B Step Therapy Programs
UnitedHealthcare·Cardiology, Hematology, Oncology +1 more·Medical Benefit Drug Policy
Effective date
Oct 1, 2026
We identified it
Sep 2, 2026
Summary
UnitedHealthcare Medicare Advantage revised its Part B Step Therapy Programs effective October 1, 2026, updating drug coverage preferences and step therapy requirements across multiple therapeutic categories including ATTR-mediated amyloidosis, colony stimulating factors, tocilizumab, and leucovorin/levoleucovorin. New and existing drugs were reclassified as preferred or non-preferred, with step therapy criteria added to three non-preferred products (Amvuttra, Armlupeg, Filkri) and removed from Avtozma, which was upgraded to preferred status.
Action Required
By September 30, 2026: Billing team must update the billing system to reflect new drug coverage preferences and step therapy requirements for Medicare Advantage Non-Employer Group MAPD plans. Specific actions: (1) Add step therapy authorization requirements in the claims system for Amvuttra (J0225), Armlupeg (Q5169), and Filkri (Q5172); (2) Remove step therapy requirements for Avtozma (Q5156); (3) Update HCPCS code mappings to use J0643 (preferred) instead of J0640 and J0644 (non-preferred) instead of C9399/J3490/J3590 for leucovorin/levoleucovorin; (4) Update drug formulary lists to reflect preferred/non-preferred status changes; (5) Train billing and prior authorization staff on new step therapy triggers. Failure to implement these changes will result in claim denials for non-compliant submissions and improper reimbursement coding.