Appeal: step therapy exception
Asks your plan to excuse you from trying other drugs first, using the drugs you have already tried and your prescriber's reasons, and to send its step therapy rules.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan will cover a prescribed drug only after you try other drugs first, and your prescriber says those drugs are wrong for you. If you have already tried the required drugs, tick the paragraph that lists them. If you have not tried them, leave that paragraph out and rely on your doctor's reasons (see the step therapy letter for your clinician, “Step therapy exception letter (for your clinician)”). Some states have step therapy laws, but they generally reach only state-regulated plans, not self-funded employer plans.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: step therapy exception Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] that denied coverage of [The drug your prescriber ordered, with the dose] under [Name of the health plan] (member ID [Member ID], reference number [Claim or reference number]) because the plan requires other drugs to be tried first. I ask you to grant an exception to that requirement and to approve [The drug your prescriber ordered, with the dose], as prescribed by [Your prescriber's name and specialty].
The plan's requirement is: [The step requirement as the plan states it]
My prescriber's reasons for saying the first-step drug is not right for me are: [Why your prescriber says the first-step drug is not right for you]
I ask the plan to consider these facts under any step therapy exception process in its drug coverage documents, and as part of this appeal. I also ask the plan to tell me what an exception request must show, so that my prescriber and I can send anything that is missing.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. Because the denial rests on a medical judgment, I also ask that you consult a health care professional with training and experience in the field of my condition who was not consulted on the first decision. Please consider every record and comment I send, including anything that was not before the first reviewer.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will ask for external review by an independent organization and may complain to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter 2. Pharmacy or medical records showing the drugs I tried 3. Letter from my prescriber explaining why the first-step drug is not right 4. The step therapy rule from the plan's drug list, if I have it
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter
- Pharmacy or medical records showing the drugs I tried
- Letter from my prescriber explaining why the first-step drug is not right
- The step therapy rule from the plan's drug list, if I have it
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls. If your prescriber says waiting could seriously harm you, ask for an expedited appeal, which must be decided within 72 hours.
- Ask your pharmacy whether it can hold the prescription or give a short supply while you appeal. The plan decides whether it will pay for it.
- If the plan says no again, or does not answer in time, ask for external review (also called independent review), which is a review by reviewers outside the plan. For most job-based and individual plans you have at least four months after you receive the final denial to ask. Check the date on your notice, which controls.
- The sources used for this letter do not set out a federal step therapy exception test, so the letter relies on your plan's own rules and the appeal rules. Some states add step therapy rights for state-regulated plans; check your state's page on this site and the denial notice.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Step therapy required
The plan wants you to try cheaper drugs first. You can ask for an exception. Holding a denial letter? File the appeal by your deadline, and ask your doctor to send the exception request at the same time.