Step therapy (also called “fail first”) requires you to try a plan-preferred drug before it will cover the one your prescriber ordered. This letter requests an exception when you already tried and failed the required drug, cannot safely take it, are expected not to benefit from it, or are already stable on your current medication. Many states require plans to offer a step-therapy override process with response deadlines, and Medicare and ACA plans have exception processes — but the controlling deadline is on your own denial letter, so check it first.
Before you appeal
- The denial letter or EOB naming the step-therapy rule and the required drug(s).
- Your prescriber’s supporting statement explaining why the exception is warranted.
- Records of prior trials: which drugs you tried, dates, doses, and the result (no benefit, side effects).
- Documentation of any contraindication, allergy, or interaction with the required drug.
- If you are stable on the current drug, records showing that control and the risk of switching.
- Your plan’s step-therapy / exception rules from the formulary or plan documents.
The letter
[Your full name]
[Your address]
[City, State ZIP]
[Phone] | [Email]
[Date]
[Insurance company - Appeals Department]
[Address from your denial letter]
Re: Request for step therapy ("fail first") exception
Member: [Name] Member ID: [number] Group #: [number]
Claim number: [number] Date(s) of service: [dates]
Denial date: [date] Denial reason/code: [as stated on the denial letter/EOB]
To the Appeals Department:
I am requesting a step therapy exception so the plan will cover
[prescribed drug] without first requiring [required/preferred drug(s)].
My prescriber, [prescriber name and specialty], ordered this medication to
treat [diagnosis].
An exception is warranted for the following reason(s) [keep what applies]:
- I already tried the required drug(s) and they failed. I took
[drug, dose, dates] and it did not work / caused [side effect].
- The required drug is contraindicated for me, or is expected to cause an
adverse reaction, because [reason].
- The required drug is expected to be ineffective for my condition based on
my clinical history.
- I am currently stable on [prescribed drug], and switching is expected to
cause my condition to worsen or relapse.
The enclosed prescriber statement and records support this request.
So that I can respond fully, please send me in writing the step-therapy
criteria and exception rules the plan applied, and the required timeframe for
deciding a step-therapy override.
Enclosed in support:
- Copy of the denial letter / EOB
- Prescriber supporting statement
- Records of prior drug trials and results
- Documentation of contraindication / current stability (if applicable)
Please send me a written decision by the plan's required timeframe. If this
request is denied, please send the information I need to take the next step.
Thank you,
[Your signature]
[Your printed name]
How to send it
File within your plan’s deadline — the date is on your denial letter. Use certified mail with return receipt, or your plan’s official appeals or pharmacy-exception channel (fax, portal, or member-services address), and keep a dated copy. If going without the medication could seriously harm your health, ask for the expedited override timeframe so the plan must decide quickly.
Notes. Many states have step-therapy override laws that require plans to grant an exception (and respond within a set time, often 24-72 hours for urgent requests) when the patient has already failed, cannot tolerate, is expected not to benefit from, or is stable on the current drug; Medicare Part D and ACA plans run similar coverage-exception processes. The exact criteria and deadlines depend on your plan and state, so confirm them in your plan documents. See also request a formulary drug exception, appeal a ‘not medically necessary’ denial, and the internal appeal letter. This is general information, not legal or medical advice.