What are the standard grounds for a step therapy exception for GLP-1s?

The five grounds most state override statutes and plan exception procedures recognize are: 1) Contraindication to the required drug, 2) Documented severe adverse reaction, 3) Previous trial and failure, 4) Expected ineffectiveness, and 5) Clinical stability on the requested drug. Self-funded employer (ERISA) plans are generally exempt from state statutes; the same grounds go through the plan's own exception and appeal process instead.

State Override Statutes · Clinical Exceptions

Overriding step therapy for GLP-1 medications

Insurance plans often demand you "fail first" on older, cheaper drugs (metformin, phentermine, or older GLP-1s) before approving Zepbound or Wegovy. Most states have enacted some form of step-therapy reform, and even where no statute applies, plan exception procedures recognize the same clinical grounds.

The Strategy in One Minute

Insurance plans often demand you "fail first" on older, cheaper drugs before approving newer GLP-1s. But most states have enacted step-therapy reform statutes, and the clinical exception grounds they codify are the same ones plan formulary-exception procedures recognize everywhere else — so the physician attestation below works in either regime.

Standard Rule: Fail-First Mandate (Blocked / Delayed)
PBMs demand trial and failure on 1 to 3 older medications (such as phentermine or metformin) before approving Zepbound or Wegovy.

Clinical Exception (Direct Approval)
Physician attests contraindication, past intolerance, or stable therapy. Where a state statute applies, it comes with a decision deadline; elsewhere the plan's own exception process handles the same request.

Check which regime your plan is in first. Self-funded employer plans — common at large employers — are governed by federal ERISA rules and are generally exempt from state step-therapy statutes. The five grounds below still work there, but through the plan's own formulary-exception process and ERISA appeal rights (see the appeals page) rather than a state-mandated clock. Your HR or benefits documents say whether the plan is self-funded or fully insured; you can look up your state's protections on the National Psoriasis Foundation's state-by-state tracker.

The 5 Legal Grounds for a Step Therapy Exception

These are the grounds the model step-therapy legislation codifies and most enacted statutes follow; plan exception guidelines recognize the same five. Where a statute applies, the plan must grant the exception if your prescriber certifies one of them:

1. Contraindication: The required step-1 drug is contraindicated for the patient (e.g. renal impairment, uncontrolled hypertension, history of arrhythmias, or drug interactions).
2. Documented Adverse Reaction: The patient has previously experienced a severe adverse event, physical harm, or intolerable gastrointestinal side effects from the required drug.
3. Previous Trial & Failure: The patient previously tried the step-1 medication for an adequate trial duration (under their current or a previous health plan) without clinical efficacy.
4. Expected Ineffectiveness: Based on sound clinical evidence or the patient's medical characteristics, the step-1 medication is reasonably expected to be ineffective.
5. Treatment Stability: The patient is already stable on the prescribed GLP-1, and switching to a step-1 medication would disrupt therapeutic stability or cause physical harm.

Statutory Decision Deadlines

Where a state statute pins a decision clock, the windows below are the ones most commonly legislated — but only a minority of reform states pin these exact numbers, some use others (48 hours, for example), and many set no deadline at all. Self-funded ERISA plans follow federal prior-authorization turnarounds instead (those are on the appeals page). Look up your state before counting on a clock:

Standard Request: Commonly 72 Hours
Statutes that set a standard-request deadline most often require a written decision within 72 hours of complete clinical documentation. A few deem an unanswered request granted after the deadline — most do not, so never rely on silence.

Urgent / Expedited Request: Commonly 24 Hours
Where a delay would seriously jeopardize the patient's health, statutes that set an expedited deadline most often require a decision within 24 hours.

State-by-state provisions: steptherapy.com's legislation tracker.

Sample Prescriber Override Attestation

Physicians can include this override paragraph in their prior authorization submission or appeal letter:

Prescriber Exception Letter

Re: Step Therapy Override Request for [Requested Drug: e.g. Zepbound 5mg] Patient: [Patient Name] | DOB: [DOB] | Member ID: [Member ID] Dear Medical Director, I am requesting a step therapy override exception on behalf of my patient, [Patient Name], for the prescribed medication [Requested Drug]. The plan requires prior trial and failure of [Required Step 1 Drug: e.g., phentermine/topiramate or older formulation]. This step-therapy requirement should be waived under standard exception criteria because: [ ] CONTRAINDICATION: The patient has a documented contraindication to [Step 1 Drug] due to [specify condition, e.g. cardiovascular disease, glaucoma, renal insufficiency]. [ ] ADVERSE EVENT / INTOLERANCE: The patient previously trialed [Step 1 Drug] from [Date] to [Date] and experienced severe adverse reactions ([specify symptoms]). [ ] STABLE THERAPY: The patient is currently stabilized on [Requested Drug] with documented clinical efficacy ([specify weight/metabolic progress]) and switching would cause therapy disruption. Supporting clinical records and chart notes are attached. Please provide a written determination within the timeframe required by applicable state step-therapy statutes or, where those do not apply, by the plan's own exception and appeal procedures. Sincerely, [Prescriber Signature] [NPI Number]

Look Up Your PBM's Step Therapy Policy

Inspect verified insurer criteria and federal appeal rights:

PBM Criteria

Browse PBM Formulary Policies

See exact step therapy criteria and exception forms for CVS Caremark, Express Scripts, and Optum Rx.

Appeals Hub

Check Appeal Deadlines & Rights

Internal appeal deadlines by coverage type, decision turnarounds, and external independent review rights — from primary federal sources.