CurrentHealthPartnersPolicy N/A

2025 Medicare Part D Step Therapy Requirements (selected medications)

Defines step therapy prerequisites for specific outpatient medications under HealthPartners' 2025 Medicare Part D benefit; affects Part D claims and prescribers/pharmacies submitting for beneficiaries.

Policy Summary

PayerHealthPartners

Policy2025 Medicare Part D Step Therapy Requirements (selected medications)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionDocument prior claim or prior use evidence (e.g., injectable insulin claim within 120 days or prior mupirocin/levodopa/tazarotene use within 12 months) when submitting for Part D coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4distinct step therapy entries listed

120 daysinjectable insulin look-back

12 monthsother medication look-back

Medicare Part D Step Therapy Coverage Criteria

Injectable insulin

Injectable insulin coverage under Part D is contingent on prior claim evidence as follows.

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Look-back Periods and Coding Notes

Injectable insulin prior claim look-back — 120 days

Threshold120 days look-back for a prior claim of an injectable insulin

ApplicabilityApplies to Part D payment qualification for injectable insulin

Required evidenceA prior claim for an injectable insulin within the past 120 days

Consequence of missing evidenceAbsence of a prior claim within 120 days may prevent Part D payment

General prior-use look-back — 12 months (mupirocin, carbidopa-levodopa, tazarotene)

Threshold12 months look-back for specified prior-use requirements

Mupirocin requirementPrior use of mupirocin ointment within the previous 12 months is required for mupirocin 2% cream

Carbidopa‑levodopa requirementPrior use of carbidopa-levodopa (IR or ER) within the previous 12 months is required for RYTARY

Tazarotene requirementPrior use of tazarotene 0.1% cream within the previous 12 months is required for listed tazarotene products

What Providers Must Do / Documentation to Support Coverage

Documentation Required

Injectable insulin — prior claim required

A prior claim for an injectable insulin within the past 120 days will qualify the member for Part D payment for injectable insulin. Document and cite the prior claim date when submitting for Part D coverage.

Prior claim within 120 days required
Affects injectable insulin billing under Part D

Step Therapy

Mupirocin 2% cream — step requirement

Prior use of mupirocin ointment within the previous 12 months is required to meet the step-therapy requirement for coverage of mupirocin 2% cream. Include medication name, fill date, and prescriber in the documentation.

Mupirocin ointment use within 12 months required
Document medication, date, and prescriber

Step Therapy

RYTARY — prior carbidopa‑levodopa required

Prior use of carbidopa‑levodopa immediate‑release (IR) or extended‑release (ER) within the previous 12 months is required to meet the step-therapy requirement for RYTARY. Provide records of IR or ER therapy (product name and dates) when requesting coverage.

Carbidopa‑levodopa IR or ER use within 12 months required
Document product name and dates to support RYTARY coverage

Step Therapy

Tazarotene products — prior topical tazarotene required

Prior use of tazarotene 0.1% cream within the previous 12 months is required to meet the step-therapy requirement for listed tazarotene creams/gels. Supply documentation showing prior tazarotene 0.1% cream use (date and prescriber) with the prior authorization or claim.

Tazarotene 0.1% cream use within 12 months required
Applicable to listed tazarotene creams and gels; document date and prescriber

Step Therapy Table

Medication	Step requirement	Look-back period
Injectable insulin
Prior claim for an injectable insulin is required to qualify for Part D payment.
120 days

Medication	Step requirement	Look-back period
Mupirocin 2% cream
Prior use of mupirocin ointment is required before coverage.
12 months

Medication	Step requirement	Look-back period
RYTARY (carbidopa-levodopa)
Prior use of carbidopa-levodopa immediate release or extended release is required before coverage.
12 months

Medication	Step requirement	Look-back period
Tazarotene products (0.05%–0.1% formulations)
Prior use of tazarotene 0.1% cream is required before coverage of listed tazarotene products.
12 months

Policy Summary

PayerHealthPartners

Policy2025 Medicare Part D Step Therapy Requirements (selected medications)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionDocument prior claim or prior use evidence (e.g., injectable insulin claim within 120 days or prior mupirocin/levodopa/tazarotene use within 12 months) when submitting for Part D coverage.

SourceLink

On This Page

OpenPayer

2025 Medicare Part D Step Therapy Requirements (selected medications)

Medicare Part D Step Therapy Coverage Criteria

Look-back Periods and Coding Notes

What Providers Must Do / Documentation to Support Coverage

Initial Therapy Requirements

Step Therapy Table