Step Therapy Exception · PAMS Access Toolkit

Check this before anything else

Is this plan fully insured or self-funded?

Most state step-therapy laws do not reach self-funded employer plans, which are governed by federal ERISA rather than state insurance law. A large share of commercial coverage is self-funded, and the member's card usually does not say so. If the plan is self-funded, the state exception route is unavailable and the argument has to be made through the plan's own exception process instead.

Ask the plan directly whether the member's coverage is fully insured or self-funded.
A third-party administrator name on the card that differs from the carrier is a hint, not proof.
Medicare, Medicaid and TRICARE follow their own rules and are outside state step-therapy law entirely.

Which route are you on?

Find this out firstUntil you know whether the plan is fully insured or self-funded you don't know which route you are on — and they have different deadlines and different forms. One phone call to the plan settles it.

TimeframesMany state statutes set a response deadline for exception requests, commonly 72 hours standard and 24 hours expedited — but this varies by state and is NOT asserted here. Read the statute or the plan policy for the number that actually applies.

Which ground applies?

tick all that apply

Common across statutes and plan policiesThese four grounds appear, in some form, across most state step-therapy override statutes and most plan exception policies. The wording and the evidence standard vary by state and by plan — confirm both.

What to look for in the chart

5 to check

Tell it what the plan wants firstSet Step they want first above and this narrows to the objections that fit that specific step. Right now it is showing only the ones that apply whatever they ask for.

Concurrent medications that may contraindicate the required stepCurrent use of atorvastatin, simvastatin, NSAIDs, diclofenac, omeprazole or acetaminophen.Flag to the prescriber for a contraindication decision. This is a prompt to ask, not a finding.
History of cancerOncology history and any standing advice on immunomodulator use.Narrows the alternatives materially and is a prescriber decision, not a coordinator one.
Latex sensitivityDocumented latex allergy against the device the required product uses.A device property, not a drug property. Check the specific presentation.
The requested product has a materially less frequent scheduleThe maintenance interval of the requested product against the one they want first. Both are on each product's card in the Therapy Reference tool.Adherence is a legitimate argument and it is now computable from our own data: q12w against twice weekly is a 24-fold difference in injection events.
Documented functional impactOccupational impact and personal impact, including psychosocial and intimate consequences, recorded in the chart in the patient's own terms.The instrument scores in T8 quantify severity; this is the part they do not capture.

Ask, do not assertNone of this is clinical direction. It is a checklist of what a prescriber may already have documented, surfaced so the coordinator can ask rather than guess.

Before you write the appeal

Denial reason is 'missing information'An appeal is the wrong instrument. If the supporting documentation went with the original request, ask for the PA to be re-run against it rather than opening an appeal, and say so explicitly on the fax back to the PA line. An appeal restarts a clock that a re-run does not. This is the single cheapest correction in the whole set.

Appeal deadline90 days from receipt of the denial, stated consistently across the binder's product sections. It is a hard stop, and it is the date the patient needs if they file their own appeal.

A state step-therapy exception cover sheet exists for this stateObtain it from steptherapy.com under State Action, select the state, download the exception letter, and send it with the appeal. Only helps where state law reaches the plan -- check the ERISA gate first.

Diagnosis-specific movePhototherapy counts as a systemic step in most plans and is far easier to document than a methotrexate trial. If the patient can't get to a box, say so explicitly — distance and access are accepted contraindications.

Request outline

STEP THERAPY EXCEPTION — request outline
Skyrizi · Psoriasis · commercial
Plan funding: NOT YET ESTABLISHED

ROUTE
  UNKNOWN — establish plan funding first

GROUNDS CLAIMED
  (none selected)

CHART EVIDENCE TO PULL
  [ ] Concurrent medications that may contraindicate the required step — Current use of atorvastatin, simvastatin, NSAIDs, diclofenac, omeprazole or acetaminophen.
  [ ] History of cancer — Oncology history and any standing advice on immunomodulator use.
  [ ] Latex sensitivity — Documented latex allergy against the device the required product uses.
  [ ] The requested product has a materially less frequent schedule — The maintenance interval of the requested product against the one they want first. Both are on each product's card in the Therapy Reference tool.
  [ ] Documented functional impact — Occupational impact and personal impact, including psychosocial and intimate consequences, recorded in the chart in the patient's own terms.

ATTACH
  [ ] Current severity score, recorded numerically (IGA)
  [ ] Structured treatment history — therapy, duration, outcome, reason discontinued
  [ ] Quality-of-life impact in the patient's own words
  [ ] The state exception form, if the state mandates one

Confirm the statute and the plan policy before filing. No patient identifiers recorded.

Where to get the law

National Psoriasis Foundation step therapy tracker
State-by-state legislative status
steptherapy.com — State Action
Downloadable state exception letters where they exist
The state's Department of Insurance
The statute and any mandated form
The plan's own medical policy
The exception process the plan actually runs

Why we don't hold thisWe do not record what any state's step-therapy law says. Statutes differ and change, and a request filed under a statute that doesn't apply is worse than none. This tool builds the argument and routes you to the current law — it does not substitute for it.

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