Step therapy required: how to appeal
The insurer requires you to try a preferred lower-cost drug or service before approving the requested one. Documented prior trial and failure of the step drug.
Why this denial happens
- Newer or brand-name therapy when a generic is available
- Plan-preferred biologic over the requested one
- Documentation of prior therapy missing
What overturns it
- Documented prior trial and failure of the step drug
- Contraindication to the step drug
- Specialist letter explaining clinical reason for the preferred therapy
Evidence checklist
- ✓Pharmacy claims history
- ✓Office notes describing failure or side effects
- ✓Specialist letter
Most states have step-therapy override laws requiring exceptions for documented failure, contraindication, or expected adverse outcome.
Draft an appeal for a "Step therapy" denial
Free analysis identifies the cited policy and missing evidence. Then a finished letter.
FAQ
What does "Step therapy required" mean on a denial letter?+
The insurer requires you to try a preferred lower-cost drug or service before approving the requested one.
How long do I have to appeal?+
180 days from the date of denial for ERISA group plans and ACA marketplace plans. 60 days for Medicare Advantage. Check the denial letter for your specific deadline.
What is the success rate for this kind of appeal?+
Outcomes vary, but medical-necessity and step-therapy appeals overturn at meaningful rates when the appeal cites the insurer's own policy and the chart documents the required criteria.
Other denial reasons
Not legal or medical advice. This page is a self-help resource. You make your own decisions. Strip personal identifiers (name, date of birth, address, member ID) from any document before uploading or sharing. The information here summarizes commonly-published payer policies and federal rules; confirm against your specific plan document and the current denial letter before acting.