Step Therapy

Deep dive

Step Therapy: complete reference

Step therapy (also "fail-first therapy") is an insurance utilization-management protocol that requires patients to try and "fail" lower-tier medications before approving higher-tier alternatives. For GLP-1 medications, step therapy typically requires: documented trial of metformin (for diabetes patients), failed lifestyle intervention attempt (for weight management), and often trial of older anti-obesity medications (phentermine, naltrexone-bupropion, or orlistat) before approving GLP-1. Insurance plans use step therapy to control costs by encouraging less-expensive treatments first. Patient experience: prescriber writes for Wegovy, insurance denies, requires documentation of failed step therapy. To navigate: document any prior medication trials with dates + reasons for discontinuation, document lifestyle intervention attempts with structured programs, consider whether stepping through cheaper alternatives makes clinical sense vs appealing with medical necessity letter. Some prescribers can request "step therapy exception" — bypassing step requirements if medical contraindication to lower tiers exists.

In practice

Your insurance denies Wegovy saying "must try phentermine first." Your prescriber documents your previous phentermine trial that caused tachycardia, then resubmits — granted on appeal.

Clinical context

Step therapy is common for GLP-1 weight indications. Document failed prior treatments to facilitate appeals.