Step Therapy Exception Appeal Letter Template

Step Therapy Exception Appeal Letter

[Your Name] [Address] [Date]

[Insurance Company] [Appeals Department Address]

RE: Step Therapy Exception Request Member: [Your Name] ID: [Policy Number] Medication: [Prescribed Drug Name] Claim/Auth #: [Number] Date of Denial: [Date]

Dear Appeals Review Committee:

I am requesting an exception to the step therapy requirement for [prescribed medication] based on the following clinical grounds:

1. Medical History and Current Condition I have been diagnosed with [condition] and my treating physician, Dr. [Name], has prescribed [medication] based on my specific clinical profile. 2. Clinical Rationale for Exception

[Choose applicable reasons:]

☐ Previous trial and failure: I previously tried [step drug] from [date] to [date]. It was discontinued because [specific reason — side effects, lack of efficacy, clinical deterioration].

☐ Contraindication: The required step therapy drug is contraindicated because [specific medical reason].

☐ Risk of harm: Requiring a trial of [step drug] would cause a delay in treatment that risks [specific harm — disease progression, irreversible damage, hospitalization].

☐ Clinical evidence: Peer-reviewed literature supports [prescribed drug] as first-line for my specific condition profile. [Cite specific studies.]

3. State Law Reference

[If applicable] Under [state] step therapy reform law [cite statute], patients are entitled to exceptions when [applicable criterion is met].

4. Requested Action

I request that the step therapy requirement be waived and [prescribed medication] be approved as prescribed by my physician.

Sincerely, [Your Name]

Supporting Documentation

• Physician letter of medical necessity
• Documentation of previous medication trials
• Relevant lab results and clinical records
• State step therapy reform law citation
• Peer-reviewed literature supporting prescribed medication