Medicare Part B Step Therapy Programs – Medicare Advantage Medical Benefit Drug Policy | UHC Coverage Update

TL;DR: UnitedHealthcare modified its Medicare Part B step therapy coverage policy (medicare-part-b-step-therapy-programs), effective January 1, 2026, updating preferred and non-preferred drug designations across dozens of injectable drug classes. Billing teams that administer non-preferred agents without prior authorization will face claim denials.

UnitedHealthcare's Medicare Advantage step therapy programs — covering everything from oncology antiemetics to intravitreal VEGF inhibitors — got a full drug list refresh for 2026. This policy governs which injectable drugs Medicare Advantage members can receive without jumping through prior authorization hoops, and which require step therapy documentation first. Affected HCPCS codes span well over 100 billing codes, including J0178 (aflibercept), J2506 (pegfilgrastim), J1745 (infliximab), J1299 (eculizumab), J2469 (palonosetron), and dozens more across oncology, ophthalmology, immunology, and rheumatology.

Quick-Reference Table

UnitedHealthcare Medicare Advantage Step Therapy Coverage Criteria and Medical Necessity Requirements 2026

The UnitedHealthcare Medicare Part B step therapy coverage policy works as a layer on top of Medicare NCDs, LCDs, and CMS manuals. It doesn't replace medical necessity requirements — it adds drug preference tiers that determine whether prior authorization is required.

Here's the core rule: if you administer a non-preferred drug without a prior authorization, UnitedHealthcare can deny the claim. Full stop. Medical necessity alone doesn't protect you if you skipped the step therapy authorization process.

Authorization, when approved, runs for 12 months. That's a useful planning window, but it means your team needs a tracking system. Authorizations that lapse mid-treatment will create claim denial exposure on renewal dates.

The Current Drug Protections — Read These Carefully

This policy includes two protections that your billing team and your prescribers need to understand before the January 1, 2026 effective date.

Protection one: A member with a paid claim for any drug within the past 365 days cannot be forced to switch to the preferred alternative. This applies to new UnitedHealthcare enrollees who bring claim history from another plan, and to existing members if UnitedHealthcare updates the preferred drug list mid-year.

Protection two: If UnitedHealthcare updates this coverage policy and a current member is already on a drug — meaning a paid claim exists in the past 12 months — that member does not need to switch. The new preferred/non-preferred designations apply to new starts, not existing therapy.

These protections are meaningful, but they require documentation. Your billing team needs to pull claim history for Medicare Advantage patients before assuming a non-preferred drug requires step therapy authorization.

Step Therapy Structure

The policy organizes drugs by therapeutic class. Each class has a preferred tier and a non-preferred tier. To bill a non-preferred agent, you need to document that the preferred option was tried and failed, is contraindicated, or is otherwise clinically inappropriate — then get the prior authorization before administering the drug.

UnitedHealthcare Medicare Advantage step therapy billing requires this sequence: preferred drug trial documented, medical necessity for the non-preferred agent established, authorization requested and approved, then administration. Skipping any step in that sequence puts reimbursement at risk.

UnitedHealthcare Medicare Advantage Step Therapy Coverage Indications at a Glance

This table summarizes the preferred vs. non-preferred structure across the major drug classes covered under this policy. Every row comes directly from the policy document.

UnitedHealthcare Medicare Advantage Step Therapy Billing Guidelines and Action Items 2026

This is where the financial exposure is real. The preferred/non-preferred lists changed with the January 1, 2026 effective date. Drugs that were preferred last year may be non-preferred now, or vice versa. Here's what your billing team needs to do right now.

If you're a high-volume infusion center or oncology practice with significant Medicare Advantage patient volume, talk to your compliance officer before submitting January 2026 claims. The preferred drug list changes are broad enough that a systematic audit is worth the time.

HCPCS Codes for Step Therapy Injectables Under UHC medicare-part-b-step-therapy-programs

The policy lists over 199 HCPCS codes. Below are the primary codes by drug class drawn directly from the policy data. Use these for charge capture validation, prior authorization requests, and claim edits.

Preferred Drug Codes (Step Therapy Criteria Must Be Met for Non-Preferred Alternatives)

Note: The full policy lists 199 HCPCS codes. The codes above cover the primary drug classes discussed in the policy summary. For the complete code list with all biosimilar-specific codes and antineoplastic monoclonal antibody PD-1/PD-L1 codes, see the full policy at app.payerpolicy.org.

No ICD-10-CM codes are listed in this policy document.