Step Therapy Reform Act

The Step Therapy Reform Act is in effect starting on Jan. 1, 2022, for health benefit plans as defined in the Act.

The Step Therapy Reform Act allows health care providers to request a step therapy override exception, provides certain circumstances when a health care provider can override the step therapy protocol and establishes timelines for which an insurance company or pharmacy benefit manager must respond when a step therapy override exception request is submitted. The override exception process is in addition to any current appeals process.  

Review Process 

Except in the case of an urgent care request, a health carrier or utilization review organization shall decide to approve or deny a request for a step-therapy override exception within five calendar days after receipt of complete, clinically relevant written documentation supporting a step-therapy override exception.  

In the case of an urgent care request, a health carrier or utilization review organization shall approve or deny a request for a step-therapy override exception within 72 hours after receipt of such documentation. If a request for a step-therapy override exception is incomplete or additional clinically relevant information is required, the health carrier or utilization review organization may request such information within the applicable time provided in this section. Once the information is submitted, the applicable time for approval or denial shall begin again. Per the Act, completed requests for a step-therapy override exception outside the indicated timeframe will be granted.  

Rationale will be provided, and the current appeals processes will be followed, if an adverse benefit determination for a step-therapy override exception is determined. Please note, a prior authorization request is a separate process and review from a step therapy override exception request.