Step Therapy Requirement: Definition, Rules, and Examples

Here is the reality that sets the stakes, Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, and a meaningful share were denied or delayed, which is exactly where step therapy tends to surface. See the KFF analysis for the topline numbers in plain language, Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024. If you run an outpatient clinic, this policy environment touches access, throughput, and staff workload every week.

Why it matters for access, throughput, and workload

A step therapy requirement is an insurance rule that requires patients to try a plan preferred option first, then move to the next option if the first proves ineffective, not tolerated, or clinically inappropriate. In practice, step therapy can slow starts and increase documentation, which means extra calls, extra messages, and more follow ups across teams. The risks are simple to visualize, a new patient waits longer to begin care, a schedule slot expires because a request bounced back for missing proof, and your staff spends another afternoon gathering records that could have been captured cleanly on day one. When step therapy is identified early and documented precisely, approval cycles shorten, rework drops, and patients move through intake with fewer detours. If you are building a glossary driven education stack for staff, anchor your internal knowledge to the Solum Glossary and to pages like Insurance Prior Authorization Automation Explained so new hires have a single reference point.

How it works, the policy backbone

CMS allows Medicare Advantage plans to implement step therapy for Part B drugs, which established a widely cited precedent and clarified the idea for many leaders who do not live inside pharmacy benefit language. For the source summary, see the CMS fact sheet, Medicare Advantage prior authorization and step therapy for Part B drugs. Commercial plans and Medicaid managed care can apply similar utilization rules in their own policies. Even if your clinic does not handle Part B drugs, the operational pattern is similar when a payer expects a plan preferred step to be attempted before it will cover a higher cost option.

How a step therapy requirement typically unfolds

Think of a gated path, you advance only when the previous gate is satisfied. The flow below preserves the core steps while using language your team can put to work today.

1. The plan defines a preferred sequence
   A payer policy specifies what must be tried first. This can be a lower cost medication within a class, a preferred formulary option, or a standard approach that must be attempted before a higher cost option is considered.
2. The provider recommends a treatment plan
   Clinically, you choose what is best for the patient. Operationally, you choose what can be supported and approved with the documentation you will produce.
3. The first step is attempted, or the plan requests proof that it was attempted
   If you request a later step, the plan may deny coverage until the earlier step is tried or documented. This can happen at authorization or later at claim.
4. The practice documents response, failure, or intolerance
   Precision matters here. Strong notes capture what was tried, for how long, the outcomes that were observed, and why the patient could not continue when relevant.
5. The practice requests the next step or an exception
   If the first step fails or is not appropriate, submit for the next level or request an exception, supported by specific clinical rationale that aligns with the plan’s criteria.
6. The plan reviews and issues a decision
   Timelines vary by plan and by the completeness of your documentation. Early clarity and consistent records shorten the cycle more than any single phrase ever will.

Steps to adopt this week

• Front load clarity in your intake, so your team is not surprised after a denial.
• Capture the right details the first time, so you do not need a second call.
• Route the work in one place, so nothing slips through gaps between teams.

Practical moves that pay off fast

• Use focused patient intake content, and make it persistent and reusable. For a shared reference, see What Is an Automated Intake Form?.
• Centralize messages and tasks in one queue, then assign, prioritize, and close the loop in that space. If you need a primer for staff, point to What is a Centralized Patient Messaging Hub? and Multi Provider Clinic Coordination.
• Prepare for remote intake and telehealth steps, especially when documentation timing can unlock approvals. For training pages, see Telehealth Intake: How It Works and Why It Matters.
• Align EHR and PM data to reduce retyping, then validate before submission. If you need a single explainer for your team, share How it works and the Solutions overview.
• Quantify the admin time you expect to save, and track it. A simple starting point is the ROI Calculator for Patient Communications.

Common pitfalls to avoid

• Unclear rules at intake, staff discover step therapy only after a denial because plan criteria sit in portals and PDFs that no one has time to find.
• Documentation that is clinically solid but operationally vague, reviewers look for timing, response measures, and a clear reason to move to the next step.
• Mismatch between clinical urgency and administrative pacing, patients feel the delay even when you have done everything right.
• Patient communication fatigue, repeated follow ups without a clear next step erode trust.
• Work scatter across systems, calls in one system, texts in another, portal notes in a third, which increases context switching and errors. A single queue reduces this risk, which is why Solum positions its product accordingly.

Frequently asked questions about step therapy

What is a step therapy requirement?
It is an insurance policy that requires a plan preferred option to be tried first, then coverage for the next option is considered when the first is ineffective, not tolerated, or not appropriate.

Why do insurers use step therapy?
Plans use step therapy to promote lower cost or standardized options first, which they frame as cost management and consistency, though it can create delays and extra administrative work.

How do you request a step therapy exception?
Submit specific clinical rationale that explains why the preferred option is not appropriate or has already been tried unsuccessfully, include timing, outcomes, and any adverse effects that were observed.

Is step therapy the same as prior authorization?
No, prior authorization asks for approval before coverage, step therapy dictates the order of covered options, and step therapy is often enforced through the prior authorization process.

How long can step therapy delays last?
Timelines vary by plan and by the completeness of documentation, national reporting shows weeks in some cases, faster outcomes come from early identification and exception requests when warranted.

Concise action plan

• Define the internal trigger that tells staff step therapy might apply, then document what to capture and where to store it.
• Adopt a single queue for messages and tasks, then assign work to the right role the first time.
• Standardize your exception template, include timing, outcomes, and specific clinical rationale, then train staff to submit a complete packet.
• Measure cycle time to approval and touches per request, then refine documentation and routing until you see a downward trend.

Context for readers who need to explain Solum in one sentence
Solum Health is an AI powered unified inbox and intake automation platform for outpatient facilities and specialty practices, integrated with EHR and PM systems, and built to show measurable time savings.