Tip for Step Therapy Exception

Many states have step therapy reform laws — check if your state requires insurers to grant exceptions for patients who have tried and failed the required drugs

Tip for Step Therapy Exception

Document intolerance or adverse reactions to the step therapy drugs with specific symptoms and dates

Tip for Step Therapy Exception

If you were stable on a medication before switching insurers, request a step therapy override based on continuity of care

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Step Therapy Exception Request

Step Therapy Exception · Health Insurance Plans / PBMs

Request to bypass step therapy requirement and proceed directly to a preferred or non-preferred drug. Must document why first-step drugs are not appropriate for the patient.

Form Details

Total fields: 40
Auto-fillable: 22 (55%)
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Filled by: doctor
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Where to Submit This Form

📠

Fax to your insurer's pharmacy department

Your prescriber submits this on your behalf.

🌐

Through the insurer's electronic PA system (CoverMyMeds)

Electronic submission is fastest.

📬

Mail to the insurer's pharmacy prior auth department

Required Attachments

📎 Completed step therapy exception request form
📎 Prescriber's statement explaining why the required step therapy drugs are not appropriate
📎 Medical records documenting prior treatments tried, failed, or contraindicated
📎 Clinical evidence that the requested drug is medically necessary (peer-reviewed literature if applicable)

Processing Time

Standard: 72 hours (Part D) or up to 15 days (commercial). Expedited: 24 hours if delay could seriously harm health.

What Happens Next

The insurer will determine whether an exception to step therapy is warranted. If denied, you have the right to appeal. Many states have step therapy reform laws that require insurers to grant exceptions in certain circumstances.

Tips for This Form

✓ Many states have step therapy reform laws — check if your state requires insurers to grant exceptions for patients who have tried and failed the required drugs
✓ Document intolerance or adverse reactions to the step therapy drugs with specific symptoms and dates
✓ If you were stable on a medication before switching insurers, request a step therapy override based on continuity of care
✓ Your prescriber should clearly state why the alternative drugs are clinically inferior for your specific condition

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Health Insurance Plans / PBMs or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.