Step therapy exception letter (for your clinician)
A letter in your clinician's voice asking the plan to skip a required first-try drug because it has failed, is unsafe or is otherwise not right for you. Every clinical statement is a blank for the clinician to complete.
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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. How to hand this to the office: print it or save it with the blanks showing, clip your denial letter to it, and ask the clinician to fill in every clinical blank from your chart, edit it in their own words, and sign it. You fill in only the plan details. The wording is a starting point for the clinician, who decides what is accurate for you. Use it when the plan says you must try other drugs first (step therapy) before it covers the drug your clinician prescribed. If you have a Medicare drug plan, use the Medicare drug plan exception letter instead. Your state may also have its own step therapy exception law; check your state page.
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 medical reviewer]
Re: Step therapy exception letter (for your clinician) Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am [The clinician's name], [The clinician's credentials]. I treat [The patient's full name] (member ID [Member ID]) as a specialist in [The clinician's specialty]. I am writing to request an exception to [Name of the health plan]'s step therapy requirement and to ask the plan to approve [The drug prescribed, with dose and form], as stated in its decision of [Date on the denial notice], claim or reference [Claim or reference number].
Diagnosis: [Diagnosis]
The plan requires the patient to try the following first: [The drugs the plan requires first]
In my professional judgment, this requirement is not appropriate for this patient for these reasons: [Why the required step is not appropriate for this patient]
What I expect to happen if the patient has to wait or switch: [What is likely to happen if the patient must wait or switch]
I ask the plan to approve [The drug prescribed, with dose and form] without further steps, and to give me and the patient its decision in writing. I also ask the plan to send the patient a copy of the step therapy rule or protocol it applied, which the claims rule requires it to provide free on request when it was relied on. Because this is a medical judgment, I ask that the review be done by a health care professional with training and experience in [The clinician's specialty].
I am available to speak with the reviewing clinician at [A phone number where the reviewer can reach the clinician].
Enclosures: 1. Copy of the denial letter 2. Chart notes showing prior drugs, doses, dates and results 3. The plan's step therapy policy, if you have it
Sincerely, [Your name]
Before you send it
The clinician's office can fax or upload it to the plan, or give it to you to include with your appeal. Use the appeals address or fax number on the denial notice; do not guess one. To prove it arrived, use certified mail with a return receipt, a fax confirmation page, or a portal screenshot that shows the date, and keep a copy.
What to enclose
- Copy of the denial letter
- Chart notes showing prior drugs, doses, dates and results
- The plan's step therapy policy, if you have it
What happens next
- You: give the letter and the denial notice to the prescriber's office. Ask when it will be ready and write the date down.
- Your clinician: completes the clinical blanks, picks the optional paragraphs that are true for you, signs the letter and sends it to the plan or to you. Ask for it in time for your appeal deadline.
- You: file or enclose it with your appeal. For most job-based and individual plans you have at least 180 days after you receive the denial notice to appeal, and your plan may allow more. A grandfathered individual policy may give less. Check the date on your notice, which controls.
- Plan: if the physician who knows your condition says in writing that the matter is urgent, a plan under the federal claims rule must treat it as urgent and decide an urgent appeal within 72 hours. Otherwise the plan decides whether the matter is urgent using the federal definition. Ask the plan to confirm the date it received the letter.
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.