29+ states have override laws — learn which apply to your plan and how to invoke them with state-by-state reference.
Step therapy is a requirement that patients try lower-cost treatments before an insurer will approve a more expensive or preferred option. For example, a plan may require trying two generic medications before approving a brand-name drug.
Step therapy requirements are the most common unmet criteria in prior authorization denials. If you have already completed these steps — even years ago with a different provider — that history must be documented and submitted.
Step therapy override laws require insurers to allow patients to bypass step therapy requirements under specific circumstances. More than 29 states have enacted these protections. However, these laws apply only to state-regulated (fully insured) commercial plans — they do not apply to self-insured ERISA plans, which are governed by federal law.
| Plan Type | Override Laws Apply? | Governing Authority |
|---|---|---|
| Commercial fully insured (state-regulated) | Yes — if your state has a law | State Department of Insurance |
| Self-insured / ERISA employer plan | No — federal law governs | Department of Labor (EBSA) |
| Medicare Advantage (Part C) | Partial — CMS has some protections | Centers for Medicare & Medicaid Services |
| Medicaid managed care | Varies by state | State Medicaid agency |
Most state override laws require exceptions under one or more of the following circumstances:
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