Scenario
My doctor ordered a certain treatment, but my plan denied my claim. My plan said I must try another, less expensive treatment first. My plan will only consider my claim for the treatment my doctor ordered if the less expensive treatment does not work.
Where to start
Information on the plan’s “fail-first” policies or step therapy protocols.
To determine whether the plan’s MH/SUD benefits and medical/surgical benefits are being provided comparably, you can request information regarding the basis for determining which mental health and substance use disorder benefits and medical/surgical benefits are subject to “fail-first policies” or “step-therapy protocols.”
“Fail-first” policies or “step-therapy protocols” are plan medical management tools. The basis may, for example, be the cost of treatment, medical guidelines, or a combination of factors, but they need to be applied comparably across MH/SUD benefits and medical/surgical benefits.
When can I get these documents?
Promptly, but generally not later than 30 days after your request. Shorter time limits apply in the case of urgent care claims.
