Step-therapy ('fail-first') denials
Step therapy requires you to try and fail a cheaper alternative first. Appealable when you've already tried it, when it's medically inappropriate, or when the required drug is on shortage.
What this denial means
A step-therapy denial means the plan requires you to try one or more 'preferred' drugs and fail them (or document a clinical reason you can't try them) before it will cover the requested drug. The preferred drugs are usually generics, older brands, or biosimilars. Plans use step therapy for cost containment, but federal law and most state step-therapy reform laws require exceptions for clinical inappropriateness.
How to appeal it
Step-therapy appeals win when the appeal documents one of: (1) the patient has already tried and failed (or been intolerant to) the required step drug; (2) the required drug is medically contraindicated for this patient (allergy, comorbidity, drug interaction); (3) the required drug is on FDA shortage and unavailable; (4) the patient is already stable on the requested drug from a prior plan and switching would destabilize; (5) the step requirement violates the relevant specialty-society guideline. Many states have step-therapy reform laws (~30 states by 2024) that REQUIRE plans to grant exceptions in these cases.
Frequently asked questions
What does “denied for not completing step therapy” mean?
A step-therapy denial means the plan requires you to try one or more 'preferred' drugs and fail them (or document a clinical reason you can't try them) before it will cover the requested drug. The preferred drugs are usually generics, older brands, or biosimilars. Plans use step therapy for cost containment, but federal law and most state step-therapy reform laws require exceptions for clinical inappropriateness.
How do I appeal a step-therapy ('fail-first') denials?
Step-therapy appeals win when the appeal documents one of: (1) the patient has already tried and failed (or been intolerant to) the required step drug; (2) the required drug is medically contraindicated for this patient (allergy, comorbidity, drug interaction); (3) the required drug is on FDA shortage and unavailable; (4) the patient is already stable on the requested drug from a prior plan and switching would destabilize; (5) the step requirement violates the relevant specialty-society guideline. Many states have step-therapy reform laws (~30 states by 2024) that REQUIRE plans to grant exceptions in these cases.
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Appeal a step-therapy ('fail-first') denials denial
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