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Medicare Part B Step Therapy Programs
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 3, 2026
Summary
UnitedHealthcare's October 2026 Medicare Advantage bulletin revises its Medicare Part B step therapy program, which sets preferred and non-preferred drugs for certain oncology, osteoporosis, testosterone and iron-related drugs, effective January 1, 2027. It adds newly listed generic and branded products with HCPCS codes, moves some bone density products between preferred and non-preferred, and updates the list of plans excluded from the policy.
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What to do
by Jan 1, 2027 · 7 steps
01Billing team and oncology or infusion staff: update the drug lists and HCPCS codes in charge entry and the prior authorization tracker for UnitedHealthcare Medicare Advantage members, using the bulletin's preferred and non-preferred lists (for example, generic bortezomib, carboplatin, cyclophosphamide, docetaxel and testosterone cypionate are listed as preferred; several new brand products are listed as non-preferred).
02Before ordering or billing a non-preferred product as a new start, check that the member has a documented or paid use of the drug within the past 365 days, because the bulletin says members with that history will not be required to switch.
03Dermatology and oncology staff: for squamous cell skin cancer, the bulletin lists Libtayo (J9119) as preferred and several PD-1 and PD-L1 products as non-preferred with step therapy criteria.
04Plan enrollment: the bulletin changes the list of dual-eligible and employer group plans excluded from this policy, so confirm the member's plan ID against the list before applying the step therapy rules.
05Tell providers and infusion staff about the change before January 1, 2027.
06If a member is billed for a service the plan does not cover, the bulletin states that the practice may not collect payment unless it first gets the member's written consent acknowledging the service is not covered and that the member will be billed directly.
07The bulletin does not state the consequence of a step therapy denial, so check the UHC policy for it.
Codes mentioned
J9041J9049J9051J9054J9045J9278J9071J9073J9075J9072J9074J9076J9171J9172J9174J1071J1072C9399J3490J3590Q5166Q5161Q5165Q5171Q5173Q5136Q5162J9119J9271J9275J9277J9289J9299
Original notice
Medicare Part B Step Therapy Programs
uhcprovider.com · Always check the source before changing claims.
Related changes
See all UnitedHealthcare changes →Changes to injectable oncology drug coverage are comingHighEffective Sep 1, 2026 · Prior authorizationMaximum Dosage and Frequency (for Ohio Only)HighEffective Oct 1, 2026 · Medical Benefit Drug PolicyMaximum Dosage and Frequency (for Pennsylvania Only)HighEffective Oct 1, 2026 · Medical Benefit Drug PolicyProvider Administered Drugs – Site of CareHighEffective Oct 1, 2026 · Medical Benefit Drug PolicyBrowse every UnitedHealthcare change in the policy list
Related policy hubs
UnitedHealthcare policiesOncologyHematologyEndocrinologyDermatologyUrologyNephrologyCode J9041Code J9049Code J9051Code J9054Code J9045Code J9278Code J9071Code J9073Code J9075Code J9072Code J9074Code J9076Code J9171Code J9172Code J9174Code J1071Code J1072Code C9399Code J3490Code J3590Code Q5166Code Q5161Code Q5165Code Q5171Code Q5173Code Q5136Code Q5162Code J9119Code J9271Code J9275Code J9277Code J9289Code J9299