- Step therapy, sometimes called “fail first,” means the plan covers a prescribed drug only after one or more lower-cost drugs have been tried without success.
- Plans have an exception process. The prescriber files the request, and it is strongest when it documents a specific medical reason, such as a past failure on the required drug.
- Many plans must answer a standard request within 72 hours and an urgent one within 24 hours. A denial can be appealed, and in many cases reviewed by an independent outside organization.
Daniel had been on the same migraine medication for two years. It had taken three earlier attempts with other drugs to find it. In January his employer switched insurance carriers. In February the pharmacy told him the refill had been rejected, with a note on the screen: step therapy required.
The new plan wanted him to try two older medications before it would pay for the one that worked. He had already tried both, years earlier, under a different insurer. The new plan had no record of that.
Daniel’s situation is one of the most common ways people meet step therapy, and one of the most fixable. The fix depends on getting the right information to the plan through the right channel.
What step therapy is
Health plans keep a list of covered drugs called a formulary. Next to some drugs are short codes. “PA” means prior authorization is needed. “QL” means a quantity limit applies. “ST” means step therapy: the plan will cover that drug only after the patient has tried one or more “preferred” alternatives, which are usually generics or lower-cost brands used for the same condition.
Plans say step therapy steers patients toward treatments that are well established and less expensive, which holds down premiums. Doctors and patient groups say it can delay effective treatment and force people to repeat drugs that already failed them. Both things can be true. What matters for an individual patient is that the requirement is a default, and that a process exists to set it aside when there is a medical reason.
How to find out before you reach the pharmacy
Most people learn about step therapy the way Daniel did. It can be found earlier. Log in to your plan’s member portal, open the drug list, and search for each medication you take. Look for the “ST” code or a note under “requirements” or “restrictions.” You can also call the pharmacy benefit number on your insurance card and ask directly.
This check is especially worth doing in three situations: when you are choosing a plan during open enrollment, when your employer changes carriers, and each January, because plans can revise their drug lists from one year to the next. We cover what else to look for in Your Prescription Is Covered. That Still Doesn’t Tell You the Price.
Five reasons that support an exception
An exception request asks the plan to cover the prescribed drug without completing the steps. Plans and state laws describe the accepted grounds in slightly different words, but they come down to the same five ideas.
Already tried it
You took the required drug before, under this plan or a previous one, and it did not work or was stopped because of side effects.
It is not safe for you
The required drug is contraindicated: it conflicts with another condition you have, another medication you take, or a known allergy.
It is unlikely to work
Based on your medical history and the clinical evidence, the required drug is expected to be ineffective for your specific case.
You are stable now
You are already doing well on the prescribed drug, and switching would risk a setback.
Delay would cause harm
Waiting through the steps could lead to serious or irreversible worsening of the condition.
Daniel’s case rests on the first and fourth reasons. The strength of his request depends on proof: which drugs he took, at what dose, for how long, and what happened. A statement such as “patient has failed other therapies” is weak. A statement that lists each drug with dates and outcomes is strong.
Who does what
The request is normally filed by the prescriber’s office, because the plan requires a clinical statement. That does not mean the patient waits passively. Offices handle many of these requests, and the ones that move fastest are the ones where the patient has supplied the history.
- Ask the pharmacist to read you the exact rejection message and to tell you which drugs the plan wants tried first.
- Call the plan and ask: “What is the process for a step therapy exception, which form is used, and where should my doctor send it?”
- Gather your history. Old pharmacy printouts, patient portal records and previous insurers’ claims lists all show what you took and when.
- Send that history to the prescriber’s office with a short message asking them to file an exception, and to mark it urgent if your health is at risk.
- Three days later, call the plan to confirm the request was received and ask for the reference number.
“My plan rejected [drug] for step therapy. It requires [drug A] and [drug B] first. I took [drug A] from [month, year] to [month, year] and stopped because [reason]. I took [drug B] from [dates] with [result]. Please file a step therapy exception. I have attached my pharmacy records.”
How long the plan has to answer
The deadline depends on the kind of coverage you have. The type of plan is not always obvious from the card, so ask the plan or your employer’s benefits office which rules apply.
| Type of coverage | Standard request | Urgent request |
|---|---|---|
| Individual and small-group plans under the ACA | Federal rules require a decision on a drug exception request within 72 hours. | Within 24 hours when the situation is urgent. |
| Medicare Part D and Medicare Advantage drug coverage | Within 72 hours, counted from when the plan receives the prescriber’s supporting statement. | Within 24 hours for an expedited request. |
| State-regulated employer plans | Many states have step therapy laws with their own deadlines, often 72 hours. | Often 24 hours. Check with your state insurance department. |
| Self-funded employer plans | Governed by federal benefit claim rules instead of state step therapy laws. A decision on a pre-service request is generally due within 15 days. | As soon as possible, and within 72 hours for urgent care claims. |
An “urgent” or “expedited” request is for situations in which waiting for the standard timeline could seriously endanger your life, health or ability to regain function. The prescriber usually has to state this. If it applies, make sure the office uses that word on the form.
What to do about the medication in the meantime
The days between a rejected refill and a decision are the hardest part. Do not simply stop a medication without talking to the prescriber, since some drugs cause problems when they are discontinued abruptly.
Ask about a transition supply
Medicare drug plans must provide a temporary supply in certain situations, such as the first 90 days after joining a plan. Some commercial plans offer something similar after a carrier change. Ask.
Ask the doctor for a bridge
Offices sometimes have samples, or can write a short prescription for a small quantity that is affordable at the cash price.
Compare the cash price
For some generics, the price without insurance is modest and varies widely between pharmacies. Money spent this way may not count toward your deductible.
Check assistance programs
Drug manufacturers run copay and patient assistance programs for many brand-name medications. Eligibility rules differ, especially for people on Medicare.
If the prescriber believes the plan’s preferred drug is a reasonable option that you have never tried, taking that step is sometimes the fastest path. That is a medical decision to make with the doctor. The exception process exists for the cases where it is not appropriate.
If the exception is denied
A denial has to come in writing and has to say why. Read the reason closely. Often it is a missing detail: the plan did not receive records of the earlier drugs, or the form left a field blank. The prescriber can resubmit with the gap filled, or request a “peer-to-peer” call with the plan’s reviewing clinician.
If the plan stands by its decision, you have the right to an internal appeal, in which the plan reviews the case again with a different reviewer. The deadline for filing is printed on the denial notice. For most employer and individual plans it is 180 days. If the internal appeal fails, most plans are then subject to external review, where an independent organization that does not work for the insurer makes a binding decision. Medicare drug plans have their own sequence of appeal levels, which the denial notice also describes.
Keep a simple log: the date of each call, the person’s name, the reference number and what was promised. If the plan misses a required deadline, that log is what your state insurance department, the Department of Labor or Medicare will ask to see.
For the general appeal process, see Got a Denied Insurance Claim? Stop! Don’t Pay That Bill Yet. Step therapy is a close cousin of prior authorization, which we explain in Your Insurance Says “Prior Authorization Required.” What Does That Actually Mean?
How to avoid repeating this next year
An approved exception usually lasts for a set period, commonly up to a year, and may need to be renewed. Ask the plan for the expiration date and put a reminder on the calendar a month ahead. If you change plans, the approval does not transfer, but the paperwork behind it does. Keep a folder with the approval letter, the prescriber’s statement and your pharmacy history. Daniel’s request was approved in four days once his old pharmacy records reached the new plan. The folder he keeps now means the next carrier change will start with the evidence already in hand.
Step therapy is a starting position that plans apply automatically. Learn which drugs the plan wants tried first, give your doctor a dated record of what you have already taken, ask for an urgent review if your health requires it, and appeal if the first answer is no.
Sources: HealthCare.gov and federal regulations on prescription drug exception requests for Marketplace plans; Medicare.gov, drug plan coverage rules, exceptions and appeals; U.S. Department of Labor, benefit claims procedure rules for employer plans; National Association of Insurance Commissioners, consumer information on step therapy. This article is general information, not medical or legal advice. Talk with your prescriber before changing how you take any medication.