Step Therapy: What It Is, Why It Happens, and How to Fight Back

Denied Access Due to Step Therapy? Here’s What to Know

Have you ever gone to fill a prescription, only to be told your insurance won’t cover it until you try a different drug first? You may have just run into a practice called step therapy—and you’re not alone. This common insurance policy can delay access to the medication your doctor originally prescribed, but you may be able to fight it with the right information.

This blog explains what step therapy is, why it happens, how to check if your medication is affected, and what to do if your prescription is denied. We also cover what happens when you switch plans and your medication is suddenly no longer covered.

What Is Step Therapy?

Step therapy—sometimes called “fail first” policy—requires patients to try and fail lower-cost or older medications before a more expensive or newer drug will be covered. Even if your doctor prescribes Drug B, your insurer may insist you first try Drug A and show it doesn’t work or causes side effects.

This is typically done to reduce costs, based on the insurer’s internal list of preferred drugs (called a formulary).

Insurers and Pharmacy Benefit Managers (PBMs) use step therapy to reduce costs and standardize care. But step therapy isn’t always based on what’s best for your health.

Why Do Insurance Companies Use Step Therapy?

Here’s why it happens:

• Cost containment: Cheaper drugs are often placed first in the step process.
• Rebate incentives: PBMs may negotiate better deals with manufacturers of specific drugs, influencing placement on the formulary.
• Formulary control: Insurers limit options to a narrower list of “preferred” drugs.

While insurers say this improves safety and saves money, in practice it can delay access to effective treatment and create unnecessary stress for patients and providers.

Common Medications That May Require Step Therapy

Step therapy is especially commonly reported in the following drug categories (varies by insurance and PBM):

• Mental health medications (e.g., Abilify^®, Rexulti^®, Latuda^®)
• GLP-1 receptor agonists for diabetes or weight loss (e.g., Ozempic^®, Wegovy^®, Mounjaro^®)
• Biologics for autoimmune conditions (e.g., Humira^®, Enbrel^®, Stelara^®)
• Migraine prevention medications (e.g., Aimovig^®, Emgality^®, Nurtec^®)
• Asthma and allergy injectables (e.g., Xolair^®, Fasenra^®, Dupixent^®)
• Newer antidepressants or antipsychotics
• ADHD medications (e.g., Vyvanse^®, Adderall XR^®)
• Cholesterol medications (e.g., PCSK9 inhibitors like Repatha^®)
• Specialty cancer or multiple sclerosis (MS) drugs

These are just a few examples—nearly every drug class has plans that use step therapy to control access.

How Can You Check If Step Therapy Applies?

1. Look up your plan’s formulary (prescription drug list) on the insurer’s website.
2. Search for your medication. If you see codes like “ST” or “PA,” step therapy or prior authorization is required.
3. If your drug isn’t listed, call your plan’s pharmacy benefits number and ask:
   “Does [medication name] require step therapy? What are the criteria?”

💡 Tip: Ask for the written policy. You are entitled to see the step therapy criteria.

What If I Already Tried the Other Drugs?

You may qualify for a step therapy exception—but some insurers may not automatically process this unless you appeal. This means you (or your doctor) must provide documentation showing:

• You’ve already tried and failed the required medications
• You had side effects or adverse reactions
• The required step drug is inappropriate due to a medical condition
• You’ve been stable on your current drug and switching could be harmful

What Happens If You’re Denied?

You don’t have to accept a denial. Here’s what to do:

1. Submit a step therapy exception request (sometimes done by your doctor).
2. If denied, file an appeal. Include:
   • Details of past drug failures or contraindications
   • Relevant labs, progress notes, or pharmacy records
   • A copy of the plan’s step therapy policy
3. Request an expedited review if delay in care could harm your health. These reviews typically take 72 hours or less.

🚨 Note: Some insurers won’t evaluate your exception until you file a formal appeal. Don’t wait—ask for clarification in writing.

What to Do If You’re Changing Insurance Plans

Changing plans can reset the step therapy process. Even if you’ve already failed other meds, your new insurer may not know—or may require you to start over. If your new plan requires step therapy for a drug you’re already on, don’t panic. You can often submit a medical necessity letter or request a continuation of therapy. Keep copies of past prescriptions and denial letters, and include your treatment history in the appeal.

What About State Protections?

Some states have step therapy reform laws that:

• Require clear timelines for exceptions
• Allow exceptions based on clinical judgment
• Limit when insurers can override your doctor’s treatment plan
• Have stricter turn around times for appeals

🗺️ To find out if your state has implemented step therapy protections, consult your state's Department of Insurance or speak with your healthcare provider for the most current information.

How to Appeal a Step Therapy Denial

1. Ask your insurer for the exact reason for denial in writing
2. Request a copy of the plan’s step therapy policy or clinical criteria
3. Have your provider write a letter explaining why the drug is medically necessary and why step therapy is inappropriate
4. Include prior treatment history, lab results, or specialist opinions if available
5. Use EZ Med Appeal to simplify the appeal process and generate a strong letter

Bottom Line

Step therapy can feel like an unfair barrier between you and the treatment you need—but you have options. Don’t assume the first denial is final. With the right appeal and documentation, many patients succeed in getting exceptions approved.