Step therapy — also known as 'fail first' — requires you to try and fail on cheaper medications before your insurer will cover the one your doctor prescribed. Many states now have laws allowing overrides, and this guide shows you how to get one.
What Is Step Therapy?
Step therapy is a cost-control protocol where insurers require patients to try one or more alternative treatments before approving the prescribed treatment. For example:
- Try generic Drug A before Brand Drug B
- Try physical therapy before approving surgery
- Try a cheaper biologic before the prescribed one
Grounds for Step Therapy Exception
Most state exception laws and plan policies allow overrides when:
- You've already tried and failed the required drugs — document previous failures
- The required drug would cause harm — allergies, contraindications, drug interactions
- The required drug is not appropriate — based on your specific medical condition
- You're stable on the current drug — switching could cause harm or relapse
- The delay would cause irreversible harm — progressive conditions
How to Request an Override
Step 1: Document Prior Failures
If you've tried the step therapy drugs before (even with a different insurer), gather records showing:
- Which alternatives were tried
- Duration of each trial
- Why each was ineffective or caused adverse effects
Step 2: Physician Exception Request
Your doctor submits a step therapy exception form to the insurer, including:
- Clinical rationale for the exception
- Documentation of prior failures or contraindications
- Relevant clinical guidelines
Step 3: Appeal If Denied
If the exception is denied, file a formal appeal using your standard appeal rights.
State Step Therapy Reform Laws
As of 2025, over 30 states have enacted step therapy reform laws. Common provisions:
- Right to request exceptions
- Specific grounds for exceptions
- Timeline for insurer response (typically 72 hours for urgent, 15 days standard)
- Right to continue current medication during appeal