Step Therapy Override Request Letter Template

Letter Template: Step Therapy Override

[Your Name]
[Your Address]
[City, State ZIP]
[Date]
[Insurance Company Name]
[Pharmacy/Medical Appeals Department]
[Address]
Re: Step Therapy Exception Request
Member Name: [Your Name]
Member ID: [Your ID Number]
Medication/Treatment: [Prescribed treatment]
Prescribing Provider: [Doctor Name]
Dear Appeals Review Committee:
I am requesting an exception to the step therapy requirement
for [treatment]. My physician has determined that the
prescribed treatment is medically necessary and that the
step therapy alternatives are inappropriate for my case.
GROUNDS FOR EXCEPTION
[Check all that apply and provide details:]
☐ Previously tried and failed step therapy drug(s):
  - [Drug 1]: Tried [dates], discontinued due to [reason]
  - [Drug 2]: Tried [dates], discontinued due to [reason]
☐ Medical contraindication to step therapy drug(s):
  - [Explain contraindication — allergy, drug interaction, etc.]
☐ Step therapy drug would cause harm:
  - [Explain risk — side effects, delayed treatment, etc.]
☐ Currently stable on prescribed medication:
  - [Explain current treatment and stability]
☐ Step therapy drug not in same class/mechanism:
  - [Explain why the alternatives are not therapeutically equivalent]
PHYSICIAN SUPPORT
Enclosed: Letter from Dr. [Name] supporting this exception
request with clinical rationale.
I request approval of [treatment] without the step therapy
requirement.
Sincerely,
[Your Name]

State Step Therapy Reform Laws

Many states have passed step therapy reform laws. Check if your state:

• Requires insurers to grant exceptions for specific grounds
• Sets time limits for step therapy override decisions
• Requires consideration of prior treatment history
• Exempts certain conditions from step therapy

Tips

1. Document every failed attempt — dates, duration, results, side effects
2. Get your specialist to write the supporting letter (not just your PCP)
3. Reference state law if your state has step therapy reform legislation
4. Ask about grandfathering — if you've been on the medication before joining the plan