I unfortunately had to DO the full step therapy with Aetna before I knew about exceptions. Here's what that experience was like:

Phentermine (3 months): Lost 8 lbs the first month, gained 3 back months 2-3. Net loss: 5 lbs. Also had insomnia, dry mouth, and elevated heart rate. Documented "inadequate response."

Contrave (3 months): Severe nausea for the first 4 weeks, finally titrated to full dose, lost 7 lbs total. Also had headaches and constipation. Documented "inadequate response with side effects."

After 6 months of misery and only 12 lbs lost, I finally got approved for Wegovy. Lost 45 lbs in the next 8 months.

Six months wasted. Six months of my life spent on medications my doctor didn't think would work, that didn't work, just to check boxes for an insurance company. I'm still angry about it.

If the exception route is available, TAKE IT. Don't do what I did.

Pharmacist perspective on a little-known workaround: ask your doctor if you've EVER been prescribed phentermine or naltrexone/bupropion in the past, even years ago. Some step therapy policies accept historical trials, not just current ones.

I've had patients who took phentermine for 3 months back in 2019, documented in their chart, and that counted as satisfying Step 1. They didn't need to take it again.

Also, some plans accept trials of the individual components. If you've ever taken naltrexone (for any reason) or bupropion (for depression, smoking cessation, etc.), that may count toward the Contrave step since Contrave is naltrexone + bupropion.

Have your doctor check your full medication history. You might have already "completed" steps without realizing it.

UPDATE: My doctor submitted a step therapy exception request citing the Texas override law, my BMI of 42, and the Endocrine Society guidelines. We also noted that I was prescribed Wellbutrin (bupropion) for depression in 2022 and it didn't cause any weight loss — arguing that counts as a partial Contrave trial.

Humana responded in exactly 72 hours (legal deadline). EXCEPTION GRANTED. We're submitting the Wegovy PA now.

I would have spent 6 months on medications I didn't need if I hadn't posted here. This community literally saved me half a year of my life. Thank you, everyone.