What Is a Step Therapy Requirement in Insurance?

How Step Therapy Works

1. Your doctor prescribes Medication A
2. Your insurer says you must try cheaper Medication B first
3. Only after Medication B "fails" will they cover Medication A
4. You may need to try multiple steps before reaching the prescribed drug

Problems with Step Therapy

• Delayed treatment: Weeks or months trying medications unlikely to work
• Side effects: Unnecessary exposure to drugs your doctor didn't recommend
• Worsening condition: Your health may deteriorate during the step process
• One-size-fits-all: Ignores your doctor's clinical judgment

State Protections

Many states now have step therapy reform laws that:

• Allow exceptions when the required drug would be harmful
• Exempt patients who previously tried and failed the step drug
• Require decisions within 72 hours
• Allow override when the condition is progressive

How to Appeal

1. Ask your doctor for a step therapy exception letter
2. Document any previous trials of the step drug
3. Cite clinical reasons the step drug is inappropriate
4. Reference your state's step therapy reform law if applicable
5. Request an expedited review if delay would harm your health