CurrentUnitedHealthcarePolicy N/A

Serious Mental Illness Step Therapy Exception Form

A provider-facing form to request an exception to step therapy requirements for prescription drugs for members with serious mental illness. It collects patient, insurance, prescriber, medication, diagnosis, and attestation information to support an exception request.

Policy Summary

PayerUnitedHealthcare

PolicySerious Mental Illness Step Therapy Exception Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed exception form with a signed prescriber attestation describing one of the enumerated clinical grounds for a step therapy exception.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6distinct form sections

NCapplicable state

4exception grounds

Step Therapy Exception Criteria

Step therapy exception criteria (any)

A step therapy exception request should be supported when ONE of the following is met and documented by the prescriber:

Step Therapy Exception Grounds: (I) The required prescription drug is contraindicated or will likely cause an adverse reaction or harm to the covered person; (II) The required prescription drug is ineffective based on the known clinical characteristics of the covered person and the known characteristics of the prescription regimen; (III) The covered person has tried the required prescription drug or another in the same pharmacologic class under the current or previous health plan and discontinued due to lack of efficacy, diminished effect, or an adverse event; (IV) The covered person is currently stable on the requested prescription after prior step therapy or after a prior step-therapy exception.n=1

Prescriber must attest and sign.

Submission, Documentation, and Denial Risk

Step Therapy

Policy Summary

PayerUnitedHealthcare

PolicySerious Mental Illness Step Therapy Exception Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed exception form with a signed prescriber attestation describing one of the enumerated clinical grounds for a step therapy exception.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Documentation Required

Required form documentation

The exception request must include completed form fields for: patient demographics (name, DOB, address, phone), insurance (primary/secondary plan names and ID numbers), prescriber details (name, specialty, NPI, DEA if applicable, address, phone, office contact, email), medication and diagnosis information, and the prescriber's signature or electronic I.D. verification with date and city. Provide legible, complete information; incomplete or missing fields can delay processing.

Patient information: first/middle/last name, DOB, state, zip, phone, authorized representative (if applicable) and contact.
Insurance information: primary and secondary payer names and member ID numbers.
Prescriber information: NPI (individual), DEA (if applicable), specialty, address, contact person, phone, fax, and email.
Medication/Diagnosis: specific medication requested and the clinical diagnosis supporting therapy.
Attestation: signed prescriber attestation with date and city.

Denial Risk

Grounds for step therapy exception

Grounds for a step therapy exception must be documented in the prescriber attestation. The attestation must describe which allowable basis applies and provide clinical details supporting it. Failure to describe one of the listed grounds may result in denial.

(I) Contraindication or likely adverse reaction: the required drug is contraindicated or will likely cause harm to the patient.
(II) Likely ineffectiveness: the required drug is expected to be ineffective based on the patient's known clinical characteristics and the drug's profile.
(III) Prior trial failure: the patient previously tried the required drug or another in the same class while covered by the current or a prior plan and discontinued it due to lack of efficacy, diminished effect, or an adverse event.
(IV) Clinical stability on another drug: the patient is currently stable on a medication selected by the prescriber after undergoing step therapy or after previously receiving a step-therapy exception.

Policy Background

This form is used to request an exception to step therapy requirements for members with serious mental illness. It documents the prescriber’s clinical justification when the prescriber believes the required step agent is contraindicated or likely to cause harm, likely ineffective given the patient’s clinical characteristics, has been previously tried and discontinued for lack of efficacy or an adverse event, or when the patient is currently stable on the requested medication. The prescriber must sign the attestation and provide the clinical basis for one of these grounds to support the exception request.

Exception Grounds (Definitions)

Step therapy exception grounds

Contraindication or likely adverse reactionProvider attests that the required prescription drug is contraindicated or will likely cause an adverse reaction or harm to the covered person.

Likely ineffectiveness based on clinical characteristicsProvider attests the required prescription drug is ineffective based on the known clinical characteristics of the covered person and the known characteristics of the prescription regimen.

Prior trial with discontinuation for lack of efficacy or adverse eventProvider attests the covered person tried the required drug or another in the same pharmacologic class under the current or previous plan and discontinued due to lack of efficacy, diminished effect, or an adverse event.

Current stability on requested medication after prior step therapy/exceptionProvider attests the covered person is currently stable on the requested prescription after undergoing step therapy or after having received a prior step-therapy exception.