Step therapy
Also called: fail first
Clinical reviewer: Elena Gizzi, MSN, RN · Last checked September 18, 2026
What is step therapy?
Step therapy is a type of prior authorization that requires trying a lower-cost drug proven effective for most people with your condition before the plan covers a costlier one. Prescribers can request an exception if the required drug would be less effective or cause harm, or the other drug is medically necessary for you.
How does step therapy differ from prior authorization?
Step therapy is a type of prior authorization: coverage still depends on plan approval, but the requirement is trying a specific, cheaper drug first rather than just submitting paperwork [1][2]. For weight-loss GLP-1 medications, Cigna's standard drug list marks Wegovy and Zepbound as requiring prior authorization rather than step therapy, so the two tools can be applied differently even within the same drug class [4].
Can you skip the required step for a GLP-1?
Sometimes, through an exception request. Medicare rules let you or your prescriber ask the plan for an exception to step therapy, and the prescriber must explain that the required drug would be less effective or cause adverse effects, or that the other drug is medically necessary for you [1]. Aetna's published options include step therapy that requires members with type 2 diabetes to try metformin before a GLP-1 [3].
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This entry is for education and is not medical advice. Talk with a licensed clinician about your own situation before starting, stopping, or changing any treatment.
