Step Therapy Requirements: How to Skip the Runaround

Step therapy, sometimes called "fail first," requires you to try one or more cheaper treatments before your insurer will cover the medication your doctor actually prescribed. It is one of the most frustrating barriers in health insurance, but there are legitimate ways to bypass it.

How Step Therapy Works

When your insurer imposes step therapy, it creates a hierarchy of treatments you must try and fail before moving to the next tier. A typical step therapy protocol looks like this:

1. Step 1 (Generic): Try the cheapest generic medication first, usually for 30-90 days
2. Step 2 (Preferred Brand): If the generic fails, try a preferred brand-name drug
3. Step 3 (Non-Preferred Brand): If preferred brands fail, the insurer may approve the originally prescribed medication

The problem is that "failure" is poorly defined. You may experience side effects, inadequate response, or worsening symptoms while cycling through medications your doctor did not recommend.

When You Can Get a Step Therapy Exception

Insurers are required to grant step therapy exceptions in specific circumstances. Over 30 states have enacted step therapy reform laws. Common grounds for an exception include:

• Already tried and failed the required steps: If you tried the required medications under a previous plan or before the insurer changed its formulary, you should not have to repeat them
• Contraindication: The required step medication is medically inappropriate for you due to allergies, drug interactions, or a co-existing condition
• Switching risk: You are stable on the current medication and switching poses a clinical risk (common for epilepsy, HIV, transplant, and psychiatric medications)
• Irreversible harm: Delaying effective treatment could cause permanent damage or progression of disease
• Not FDA-approved for your condition: The step medication is not approved for your specific diagnosis

How to Request a Step Therapy Override

1. Ask your doctor to submit an exception request directly to the insurer. Most insurers have specific forms for step therapy exceptions.
2. Document prior medication history. Pharmacy records, medical charts, and doctor notes showing which medications you tried, when, and why they did not work.
3. Include clinical justification. Your doctor should explain why the prescribed medication is the appropriate choice given your medical history.
4. Reference clinical guidelines. Cite specialty society recommendations that support starting with the prescribed medication for your condition.
5. Cite state law. If your state has a step therapy reform law, reference the specific statute and the grounds for your exception.

If the Exception Is Denied

If the insurer denies your step therapy exception, you have the same appeal rights as any other prior authorization denial:

• Request a peer-to-peer review between your doctor and the insurer's medical director
• File a formal internal appeal with supporting clinical evidence
• If the internal appeal fails, file for external review with an independent reviewer
• File a complaint with your state insurance commissioner citing the step therapy reform law if applicable

Step therapy overrides are among the most commonly granted exceptions in insurance. Insurers know that forcing clinically inappropriate medication trials creates liability. A well-documented request with physician support and legal citations is difficult to deny.