Step therapy
A plan requirement to try and fail a cheaper drug before the plan covers the requested drug.
Step therapy is a cost-containment policy requiring you to try and fail (or document a clinical reason to skip) a 'preferred' drug before the plan covers a non-preferred drug. The preferred drug is usually a generic, biosimilar, or older brand. Federal law and ~30 state step-therapy reform laws require exceptions for: prior failure or intolerance, contraindication, drug shortage, stability concerns when already on the requested drug, or guideline-based clinical inappropriateness.
Frequently asked questions
What is step therapy?
Step therapy is a cost-containment policy requiring you to try and fail (or document a clinical reason to skip) a 'preferred' drug before the plan covers a non-preferred drug. The preferred drug is usually a generic, biosimilar, or older brand. Federal law and ~30 state step-therapy reform laws require exceptions for: prior failure or intolerance, contraindication, drug shortage, stability concerns when already on the requested drug, or guideline-based clinical inappropriateness.
Is this relevant to a denial appeal?
Step-therapy denials are commonly reversible with documentation of prior failure, contraindication, or shortage.
Related terms
- Prior authorization (PA)Plan approval required BEFORE a service is rendered, otherwise the plan won't pay.
- FormularyThe list of prescription drugs your plan covers, organized into tiers with different cost-sharing.
- Non-formulary drugA drug not included on your plan's covered drug list. Requires a formulary exception request for cov
Appeal a denial
Step-therapy denials are commonly reversible with documentation of prior failure, contraindication, or shortage.
Get started →Contact: hello@denialhelp.com