Step Therapy Exception: When Your Insurance Won't Cover the Right Medication

When your doctor prescribes a medication that your insurance won’t approve right away, you’re likely dealing with step therapy, a cost-control rule that forces patients to try cheaper drugs first before moving to more effective ones. Also known as fail first, this practice is common in Medicaid formulary, the list of drugs covered by state-run health programs, Medicare Part D, and private plans. But sometimes, the cheaper drug won’t work—or could even harm you. That’s where a step therapy exception, a formal request to skip the required cheaper step and get the prescribed drug approved immediately comes in.

Step therapy isn’t always about saving money—it’s about following rigid rules. For example, if you have rheumatoid arthritis and your doctor says you need biologic X, your plan might force you to try methotrexate first, even if you already tried it and it failed. Or if you’re on insulin and your insurer wants you to switch to a cheaper brand that causes dangerous lows, you need to fight back. A step therapy exception lets you bypass that. You don’t need to be a medical expert to file one. Your doctor just needs to explain why the required drug won’t work for you: allergic reaction, past failure, side effects, or medical condition. The prior authorization, the process insurers use to approve or deny certain medications before filling them form is often the same form you use to request the exception. Many people don’t realize this is a right, not a favor.

What makes this even messier is that rules change by state, plan, and even pharmacy. Medicaid coverage for prescription medications varies wildly across states, and some plans require multiple failed trials before approving an exception. Meanwhile, drugs like Dapasmart or bromocriptine—used off-label for conditions like POTS or chronic fatigue—often get stuck in step therapy loops because they’re not first-line. And if you’re on a tight budget, waiting weeks for approval while your symptoms get worse isn’t an option. That’s why knowing how to push back matters. The posts below show you exactly how to navigate this: from how to write a successful exception letter (with real templates), to what your doctor needs to include, to how to appeal if your request is denied. You’ll also find real examples from people who fought Medicaid formulary rules and won. No jargon. No fluff. Just what works.