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Step Therapy Exception: How to Ask Your Insurer to Skip 'Fail First'
What step therapy is, when an exception may apply, and a free sample request paragraph.
Step therapy ('fail first') means the plan wants you to try cheaper drugs before it covers the one your doctor prescribed. Many states have laws requiring plans to grant exceptions in certain situations, for example when the required drug is contraindicated, was already tried, or you are stable on your current drug. State laws often don't apply to self-funded employer plans, though.
Free sample appeal paragraph
I request a step therapy exception for [drug]. The plan requires prior use of [required drug]. This is not appropriate for me because [I previously tried it from (dates) and it was ineffective / caused (side effect) / it is contraindicated because (reason) / I am stable on my current medication]. Supporting records from my prescriber are enclosed.
Replace the [brackets] with your details. This is a starting point, not legal advice.
What to do
- Document prior trials with dates, doses and outcomes.
- Search '[your state] step therapy law' to see whether protections apply to your plan type.
- Ask for an expedited review if a delay could harm your health.
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Start the free checkFrequently asked questions
Do step therapy laws apply to all plans?
No. State laws generally apply to state-regulated plans. Self-funded employer plans covered by ERISA are often exempt. Medicare has its own rules.
Who submits the exception?
Usually your prescriber, but you can request one and send a letter as well.
How do I appeal a step therapy denial?
Start with the instructions and deadline on your denial letter. Gather your medical records and a letter of medical necessity, respond directly to the stated denial reason, and file an internal appeal. Keep proof of submission.
Is external review available?
For many non-grandfathered plans, independent external review may be available for denials involving medical judgment after a final internal denial, generally within 4 months. Confirm on your denial notice.
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- All appeal guides
Document preparation / educational use only. This site is not a law firm, regulator, airline, insurer, or parking operator. Nothing here is legal advice. Outcomes are never guaranteed. Review every letter carefully before sending and consult a licensed professional if you need advice about your situation.