Letter

Step therapy override request

Your plan is making you fail on a cheaper drug first. Most states have override laws with specific grounds you can cite.

Before you send this

Documentation of any prior trial of the required drug, with dates and outcome
Your prescriber willing to attest to the clinical grounds
Whether your plan is fully insured or self-funded, since state override laws only reach fully insured plans
Your state insurance department contact, in case the plan does not respond in time

[DATE]

[INSURER NAME]

Attn: Pharmacy Coverage Determinations

Re: Step therapy exception / override request

Patient: [YOUR NAME], DOB [DOB]

Member ID: [MEMBER ID]

Drug requested: [DRUG NAME, STRENGTH]

Step therapy drug required by plan: [REQUIRED DRUG]

To whom it may concern,

I am requesting an exception to the step therapy requirement for [DRUG NAME].

I am requesting this override on the following grounds:

[Keep only what applies.]

- Prior trial and failure. I was treated with [REQUIRED DRUG] from [DATE] to [DATE]. The outcome was [SPECIFIC: inadequate glycemic control with A1c of X, recurrent hypoglycemia, adverse reaction]. Documentation enclosed.

- Contraindication. [REQUIRED DRUG] is contraindicated for me because [REASON].

- Expected ineffectiveness or harm. Based on my clinical history, my prescriber expects [REQUIRED DRUG] to be ineffective or to cause an adverse reaction. Their statement is enclosed.

- Current stability. I am currently stable on [DRUG NAME] under [PLAN NAME / a prior plan]. Switching would risk destabilizing glycemic control and cause preventable hospitalization.

- Device incompatibility. [REQUIRED DRUG] is not compatible with my [PUMP OR DEVICE MODEL].

Please provide a determination in writing within the timeframe required by [STATE] law and my plan documents. If denied, please state the specific basis and provide appeal instructions.

Sincerely,

[YOUR NAME]

[PHONE]

[EMAIL]

Enclosures: prescriber statement, records of prior therapy, insurance card copy

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