From the Broomstick of Julie Baak This is the 3rd grade math explanation of how Pharmacy Benefit Managers (PBMs) work: PBM denies $300 drug. They then force […]
June 24, 2020
Access Issues, Infusion Patients, Insurance
From the Broomstick of Julie Baak This is the 3rd grade math explanation of how Pharmacy Benefit Managers (PBMs) work: PBM denies $300 drug. They then force […]
The District of Columbia has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a health care provider can request an exception.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Wyoming has step therapy protections.
This law (26-55-111) prohibits insurers from requiring patients to repeat a step therapy protocol if the patient already tried the protocol’s required medication (or another similar one) under a current or past plan and stopped because the drug was ineffective or caused an adverse reaction.
If you believe an insurance company has failed to comply with 26-55-111, you can file a complaint with Wyoming’s Department of Insurance.
Great news – Wisconsin has step therapy protections.
This law (§632.866) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 3 business days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond by the end of next business day. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Wisconsin’s step therapy protections include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §632.866, you can file a complaint with Wisconsin’s Department of Insurance.
Great news – West Virginia has step therapy protections.
This law (§33-15-40) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §33-15-40, you can file a complaint with West Virginia’s Department of Insurance.
Great news – Washington has step therapy protections.
This law (RCW 48.43.420) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 3 business days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with RCW 48.43.420, you can file a complaint with Washington’s Department of Insurance.
If you believe an insurance company has failed to comply with §38.2-3407.9:05, you can file a complaint with Virginia’s Department of Insurance.
Great news – Virginia has step therapy protections.
This law (§38.2-3407.9:05) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §38.2-3407.9:05, you can file a complaint with Virginia’s Department of Insurance.
Great news – Vermont has step therapy protections.
This law (8 V.S.A. § 4089i) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to a completed exception request with a decision within 2 business days. In cases of emergency, the insurer must respond to a completed exception request with a decision within 24 hours. Insurers must also notify that they received the request and if any information is missing within 24 hours. If the insurer does not respond within these prescribed timeframes with a denial or request for more information, the exception shall be deemed granted.
If you believe an insurance company has failed to comply with 8 V.S.A. § 4089i, you can file a complaint with Vermont Department of Insurance.
The state of Utah has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Texas has step therapy protections.
This law (Title 8, Subtitle E, Chapter 1369.0546) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Title 8, Subtitle E, Chapter 1369.0546, you can file a complaint with Texas Department of Insurance.
Great news – Tennessee has step therapy protections.
This law (Chapter No. 1020) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 2 business days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours.
Protections in Tennessee include Medicaid and marketplace plans.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Chapter No. 1020, you can file a complaint with Tennessee Department of Insurance.
Great news – South Dakota has step therapy protections.
This law (58-17H-55) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 5 calendar days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 72 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 58-17H-55, you can file a complaint with South Dakota’s Department of Insurance.
The state of South Carolina has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
The state of Rhode Island has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Pennsylvania has step therapy protections.
This law (P.L. 2068, No. 146, Section 2156) requires insurers to consider granting an exception, taking into account if:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 2 business days, but not more than 72 hours total, granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours.
Protections in Pennsylvania include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with P.L. 2068, No. 146, Section 2156, you can file a complaint with Pennsylvania Department of Insurance.
Great news – Oregon has step therapy protections.
This law (ORS 743B.602) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours or 2 business days (whichever is later) granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 1 business day. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with ORS 743B.602, you can file a complaint with Oregon’s Department of Insurance.
Great news – Oklahoma has step therapy protections.
This law (63 OK Stat § 7310) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in Oklahoma include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 63 OK Stat § 7310, you can file a complaint with Oklahoma’s Department of Insurance.
Great news – Ohio has step therapy protections.
These laws (Section 3901.832, and Section 5164.7514) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 10 calendar days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 48 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in Ohio include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Section 3901.832 (Medicaid) or Section 5164.7514 (commercial health plans, you can file a complaint with Ohio’s Department of Insurance.
The state of North Dakota has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healt care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – North Carolina has step therapy protections.
This law (§58-3-221) requires insurance companies to grant a step therapy exception if a provider demonstrates either of the following:
A provider can file an exception if the situation matches any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 24 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §58-3-221, you can file a complaint with North Carolina’s Department of Insurance.
Great news – New York has step therapy protections.
This law (§4903) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in New York include Medicaid Managed Care plans (not fee-for-service plans).
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Insurance Law §4903, you can file a complaint with New York’s Department of Insurance.
Great news – New Mexico has step therapy protections.
This law (NM Stat § 13-7-18 [2024] and Section 59A-22B-8 NMSA 1978) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Step therapy is prohibited for 1) drugs treating autoimmune conditions except in cases in which a biosimilar, interchangeable biologic or generic version is available, or 2) an off-label medication that is prescribed for the treatment of a rare disease or condition (affecting less than 200,000 people in the US).
Protections in New Mexico include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with NM Stat § 13-7-18 (2024) and/or Section 59A-22B-8 NMSA 1978, you can file a complaint with New Mexico’s Department of Insurance.
Great news – New Jersey has step therapy protections.
Starting January 1, 2026, this law (C.30:4D-7xx and C.52:14-17.28j) requires New Jersey Medicaid , the State Health Benefits Program, and the School Employees’ Health Benefits Program to grant a step therapy exception if a healthcare provider demonstrates any of the following:
If granted, the insurer shall authorize coverage for the drug prescribed by the patient’s provider at least 180 days or the duration of therapy if less than 180 days, provided that the drug is covered by the patient’s health plan.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with C.30:4D-7xx and C.52:14-17.28j, you can file a complaint with New Jersey’s Department of Insurance.
The state of New Hampshire has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Nevada has step therapy protections.
This law (NRS 689A.04043) requires insurers to grant an exception if a health care provider demonstrates any of the following:
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within two business days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with NRS 689A.04043, you can file a complaint with Nevada’s Department of Insurance.
Great news – Nebraska has step therapy protections.
This law (§44-7,115) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within five days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 72 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §44-7,115, you can file a complaint with Nebraska’s Department of Insurance.
The state of Montana has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a health care provider can request an exception.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Missouri has step therapy protections.
This law (376.2034) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 376.2034, you can file a complaint with Missouri’s Department of Insurance.
Great news – Mississippi has step therapy protections.
This law (§83-9-36) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §83-9-36, you can file a complaint with Mississippi’s Department of Insurance.
Great news – Minnesota has step therapy protections.
This law (62Q.184) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 5 days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 72 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 62Q.184, you can file a complaint with Minnesota’s Department of Insurance.
The state of Michigan has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Massachusetts has step therapy protections.
This law (Chapter 254) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 3 business days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Chapter 254, you can file a complaint with Massachusetts’s Department of Insurance.
Great news – Maryland has step therapy protections.
This law (Insurance Article §15-142) requires an insurer to grant a step therapy exception if your healthcare provider:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Insurance Article §15-142, you can file a complaint with Maryland’s Department of Insurance.
Great news – Maine has step therapy protections.
This law (24-A MRSA §4320-L) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours or 2 business days (whichever is less) indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 24-A MRSA §4320-L, you can file a complaint with Maine’s Department of Insurance.
Great news – Louisiana has step therapy protections.
This law (§22:1053 and §460.34) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in Louisiana include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §22:1053 (private plans) or §460.34 (Medicaid), you can file a complaint with Louisiana’s Department of Insurance.
Great news – Delaware has step therapy protections.
This law (Title 18 § 3381) requires insurers to grant a step therapy exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria. If a patient is currently stable, exception requests are deemed granted until determined otherwise by the insurer.
An insurer must respond within 2 business days letting a patient know whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Title 18 §3381, you can file a complaint with Delaware’s Department of Insurance.
Great news – Kentucky has step therapy protections.
This law (§304.17A-163) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 48 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §304.17A-163, you can file a complaint with Kentucky’s Department of Insurance.
Great news – Kansas has step therapy protections, but only for Medicaid.
This law (39-7,121) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours that the step therapy exception has been approved, denied, or they require more information.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 39-7,121, you can file a complaint with Kansas’s Department of Insurance.
Great news – Iowa has step therapy protections.
This law (§514F.7 Iowa Code) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within five calendar days indicating whether the step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 72 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §514F.7 Iowa Code, you can file a complaint with Iowa’s Department of Insurance.
Great news – Indiana has step therapy protections.
This law (IC 27-8-5-30, IC 27-13-7-23, or IC 5-10-8-17) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
Indiana step therapy protections include state-regulated accident & sickness plans, state-regulated commercial health plans, and public employee plans.
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within 3 business days letting a patient know whether their step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 1 business day.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with IC 27-8-5-30 (accident & sickness plans), IC 27-13-7-23 (commercial health plans), or IC 5-10-8-17 (public employee plans), you can file a complaint with Indiana’s Department of Insurance.
Great news – Illinois has step therapy protections.
These laws (§215 ILCS 134/45.1 and §215 ILCS 5/356z.80) require insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within 72 hours letting a patient know whether their step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 24 hours.
State-regulated commercial and managed care plans are also specifically prohibited from imposing step therapy requirements on treatments for Alzheimer’s.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §215 ILCS 134/45.1 and/or §215 ILCS 5/356z.80, you can file a complaint with Illinois’s Department of Insurance.
The state of Hawaii has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Georgia has step therapy protections.
This law (O.C.G.A. § 33-24-59.25) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within two business days notifying a patient that the exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with O.C.G.A. § 33-24-59.25, you can file a complaint with Georgia’s Department of Insurance.
Great news – Florida has step therapy protections.
This law (Title XXXVII, ss. 627.42393) requires insurers to grant a step therapy exception if a healthcare provider demonstrates that a patient has previously completed a step therapy protocol with another health plan, and the plan paid for the requested drug during the 90 days preceding this request.
If an insurer does deny an exception request, a healthcare provider has the right to file an appeal on behalf of a patient. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with ss. 627.42393, you can file a complaint with Florida’s Department of Insurance.
Great news – Connecticut has step therapy protections.
These laws (Chapter 700C, Sections 38A-510 and 38A-544) require insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria. Starting January 1, 2026, insurers are prohibited from requiring step therapy for longer than 30 days for drugs treating multiple sclerosis or rheumatoid arthritis. After this period, the provider may deem that treatment ineffective and authorize dispensation of and coverage for the drug originally prescribed by the provider, provided the drug is covered under the patient’s health plan. Protections in Connecticut include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal. If you believe an insurance company has failed to comply with Chapter 700C, Section 38A-510 or Section 38A-544, you can file a complaint with Connecticut’s Department of Insurance.
Great news – Colorado has step therapy protections.
This law (Colo. Rev. Stat. § 10-16-145) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria. The insurer must respond to an exception request within three business days stating whether the request is approved, denied, or they need more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with HB 1370, you can file a complaint with Colorado’s Department of Insurance.
Great news – California has step therapy protections.
This law (§1367.206) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §1367.206, you can file a complaint with California’s Department of Insurance.
Great news – Arkansas has step therapy protections.
This law (§23-79-2104) requires an insurer to grant a step therapy exception if a healthcare provider demonstrates that:
An insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §23-79-2104, you can file a complaint with Arkansas’s Department of Insurance.
Great news – Arizona has step therapy protections.
This law (§20-3654) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §20-3654, you can file a complaint with Arizona’s Department of Insurance.
Great news – Alaska has step therapy protections starting January 1, 2027.
This law (AS Sec. 21.07.160) requires insurers to provide a patient and their provider with access to a clear, convenient, and readily accessible process for requesting an exception to application of the step therapy protocol. Insurers may use its existing medical exceptions process to satisfy this requirement. Insurers are required to disclose the process to the patient and their provider, along with the information needed to process the request, and make the process available on the insurer’s website.
Insurers are required to grant grant a step therapy exception if:
Use of drug samples from a pharmacy may not be considered trial and failure of a preferred prescription drug required under a step therapy protocol.
Insurers may request information from the patient or their provider to support a step therapy exception request. Upon granting a step therapy exception request, the insurer shall authorize dispensation of and coverage for the prescription drug prescribed by the patient’s provider if the drug is covered under the health plan.
If you believe an insurance company has failed to comply with AS Sec. 21.07.160, you can file a complaint with Alaska’s Department of Insurance.
The state of Alabama has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception. If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
