Glossary
Step therapy
In one sentence
A requirement to try a cheaper drug first and have it not work before the plan will pay for the one prescribed. On GLP-1s the earlier step is often an older weight-management drug rather than another GLP-1.
Also written as ST, Fail first.
What step therapy actually means
The nickname tells you what it is: fail first. The plan wants documentation that something less expensive was tried and did not do the job, and only then will it consider the drug on the prescription.
It travels alongside prior authorization and quantity limits in the same sentence of the Medicare rules, and like them it can be added or tightened during a plan year rather than only at renewal. What the earlier step actually is varies by plan and by state, and it is the sort of detail that lives in a criteria document rather than on a formulary list.
The text it comes from
This is the wording the definition rests on. Where it decides anything for you, read the section rather than our summary of it.
Step therapy is named in Medicare's rules as one of three requirements whose tightening counts as a negative formulary change, alongside prior authorization and quantity limits: "Adding or making more restrictive prior authorization (PA), step therapy (ST), or quantity limit (QL) requirements."
42 CFR §423.100, Electronic Code of Federal Regulations, effective August 2026 · source
Where this comes from
- 42 CFR §423.100, Electronic Code of Federal Regulations, effective August 2026 — www.ecfr.gov/current/title-42/part-423/section-423.100
Where this comes up
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page says what a published rule means by a word. Which rulebook governs you depends on your plan, and your own notice and plan documents govern your case.