Plan requires step therapy but I've already tried the alternative — what do I do?
Document the prior trial + failure. Most step-therapy denials reverse on appeal with this documentation.
Step therapy denials are reversible when you can document one of: prior failure or intolerance of the required step drug; the required drug is medically contraindicated for you; the required drug is on FDA shortage; you're already stable on the requested drug from a prior plan and switching would destabilize.
Steps
- Get the chart documenting the prior trial — dates, drug, dose, outcome (failure or intolerance), and reason for discontinuation
- Submit chart notes with the appeal
- Cite the relevant clinical guideline (ACR for rheumatology, ADA for diabetes, etc.)
- Cite any state step-therapy reform law if your state has one (30+ states do)
- File internal appeal then external review
Frequently asked questions
Plan requires step therapy but I've already tried the alternative — what do I do?
Step therapy denials are reversible when you can document one of: prior failure or intolerance of the required step drug; the required drug is medically contraindicated for you; the required drug is on FDA shortage; you're already stable on the requested drug from a prior plan and switching would destabilize.
What are the steps?
1. Get the chart documenting the prior trial — dates, drug, dose, outcome (failure or intolerance), and reason for discontinuation; 2. Submit chart notes with the appeal; 3. Cite the relevant clinical guideline (ACR for rheumatology, ADA for diabetes, etc.); 4. Cite any state step-therapy reform law if your state has one (30+ states do); 5. File internal appeal then external review
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