USMLE Step 1 Guide 2026: Format, Fees, Pass Rates, Eligibility

USMLE Step 1 is the first exam of the United States Medical Licensing Examination sequence. It tests whether you can apply the foundational sciences (anatomy, physiology, biochemistry, pharmacology, pathology, microbiology and behavioral science) to clinical problems. For US medical students it usually sits at the end of the preclinical years. For international medical graduates (IMGs) it is one of the required exams for ECFMG Certification and therefore the first real gate on the road to a US residency.

For the detailed study plan, read our companion guide How to Study for USMLE Step 1.

What Step 1 is and why it matters

The USMLE is co-sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). US state medical boards use it as the exam pathway to a full medical license for MD graduates and for IMGs. Step 1 is the first of three Steps:

Since Step 1 became pass/fail, residency programs look harder at Step 2 CK scores, clinical grades and experience. That does not make Step 1 less important. A fail stays on your record, counts toward the attempt limit and can delay ECFMG Certification and your Match timeline. Read the USMLE Step 2 CK guide to see how the two exams fit together.

Exam format in 2026

Step 1 is a one-day computer-based exam in a single 8-hour testing session. The structure changed for exams taken on or after May 14, 2026. Shorter blocks replaced the old 60-minute blocks:

Under the old format the maximum was 280 items.

What the new format means in practice:

• Pacing per block changes, pace per question doesn't. Twenty questions in 30 minutes is the same 90 seconds per question as 40 in 60. You check the clock twice as often, though.
• More transitions. Fourteen block starts mean more chances to lose focus. Practice full-length sessions in the same structure.
• Break time is a budget. Finishing a block or the tutorial early can add to your break time. Decide in advance when you will take breaks, for example after every second or third block.

Questions are single-best-answer multiple-choice items, mostly built around a clinical vignette. Many ask for a mechanism, the next step in reasoning, or a lab or histology finding rather than a pure fact.

Pass/fail scoring

Step 1 has reported a pass or fail outcome only for exams taken on or after January 26, 2022. Exams taken on or before January 25, 2022 also received a three-digit score. If you fail, your report shows how far your score was from the passing standard, plus feedback by content area.

The USMLE sets a recommended minimum passing level and reviews it periodically. For its multiple-choice exams, examinees typically need to answer roughly 60 percent of items correctly to pass. The exact percentage varies by Step and test form. Treat that as orientation, not a target. Practice-test scores from commercial question banks are not on the same scale.

Eligibility

You must meet one of these criteria both when you apply and on your test day:

• You are enrolled in, or have graduated from, a US MD program accredited by the LCME.
• You are enrolled in, or have graduated from, a US DO program accredited by COCA.
• You are enrolled in, or have graduated from, a medical school outside the US that is listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements, and you meet ECFMG's other criteria.

If you are dismissed or withdrawn from medical school, you are not eligible, even while an appeal is pending.

Attempt limits

The attempt rules matter more than most candidates think:

• Four or more attempts at a Step without passing, incomplete attempts included, make you ineligible for any Step in the USMLE sequence. Attempts at the former Step 2 CS count too.
• You may not take the same Step more than three times in 12 months.
• A fourth attempt must be at least 12 months after your first attempt and at least six months after your most recent one.
• You generally cannot retake a Step you have passed.

The practical lesson: don't sit Step 1 "to see how it goes". Book the exam when your practice assessments are consistently and comfortably above the passing range.

Registration: who applies where

IMGs also need an ECFMG record. Passing Step 1 and Step 2 CK is part of the medical science exam requirement for ECFMG Certification. Our IMG pathway to US residency guide covers the full sequence.

A typical registration sequence:

1. Confirm that your school meets the eligibility criteria (US accreditation, or a World Directory listing with ECFMG eligibility).
2. Create your account with the registering organization and complete the application.
3. Pay the exam fee, plus a region fee if you will test outside the US and Canada.
4. Pick an eligibility period and receive your scheduling permit.
5. Schedule your test date at a Prometric test center as early as you can. Popular dates fill up.

Fees (as of October 2026)

Application fees for 2026 and 2027:

For students and graduates of medical schools outside the US who test outside the US and Canada, there is an extra region fee of $210 for Step 1 and $235 for Step 2 CK. These region fees are not USMLE fees. For Steps 1 and 2 taken in India, an 18% tax has applied since December 4, 2024. The USMLE program collects it and passes it on to India. US students with demonstrated financial need can apply to the NBME Fee Assistance Program.

These amounts change. IMGs also pay ECFMG fees, covered in the residency pathway guide.

Pass rates

Step 1 pass rates in 2025:

From 2025, examinees from Canadian schools are counted with non-US examinees for Step 1 and Step 2 CK. That matters for Canadian students reading older reports.

Two things follow from this data. Most first-time candidates pass. But the gap between US and non-US first takers is real. IMGs often prepare without a school curriculum built around the exam, and many study while working. A structured plan, a full question bank and official self-assessments close much of that gap.

What Step 1 covers

The content outline is organized by organ system, discipline and physician task. In practice, expect questions that combine several layers: the pathophysiology of a disease, its histology, the drug that treats it and the mechanism of that drug's side effect. Behavioral science, biostatistics, ethics and communication come up throughout.

High-yield habits for content review:

• Learn mechanisms, not lists. Vignettes rarely name the disease. They describe it.
• Link each disease to its pharmacology and microbiology.
• Practice reading lab tables, pedigrees, graphs and images quickly.
• Know basic biostatistics formulas well enough to use them under time pressure.

How to prepare: an outline

A full plan with weekly schedules is in How to Study for USMLE Step 1. The core structure:

1. Baseline (week 1). Take a diagnostic self-assessment to find weak systems and disciplines.
2. Content plus questions (most of the plan). Review by system and do timed question blocks every day from the start, not only at the end.
3. Spaced repetition every day. Short daily reviews of facts you missed keep them from fading.
4. Self-assessments at intervals. Use official NBME self-assessments to check readiness and adjust the plan.
5. Final consolidation (last 1–3 weeks). Full-length timed practice in the 2026 block structure, weak-area review, rest before test day.

MediFlow's Step 1 track has practice questions organized by system. You can try free test questions on the USMLE Step 1 course page and keep practicing in the app on your phone.

Common mistakes

• Booking too early. With strict attempt limits, a fail costs more than a few weeks' delay. Base the date on self-assessment trends.
• Passive review only. Reading and watching videos feels productive. Timed questions show what you can actually retrieve.
• Ignoring the new block structure. Practice in 30-minute, 20-question blocks so the rhythm feels normal on test day.
• Skipping behavioral science and biostatistics. These topics appear across systems and are quick wins.
• Using the wrong scale. Commercial question bank percentages don't convert directly into a pass probability. Use official self-assessments for readiness.
• Not reading the eligibility rules. IMGs especially should confirm their school's World Directory listing and ECFMG status before paying.
• Forgetting logistics. ID name mismatches and late scheduling cause avoidable stress. Check your permit details carefully.

Step 1 checklist

• Eligibility confirmed (school status, World Directory listing for IMGs)
• Registered with the right organization (NBME or FSMB)
• Fee and any region fee paid, eligibility period chosen
• Test date scheduled with Prometric
• Baseline self-assessment completed
• Daily question blocks and spaced repetition in place
• At least two official self-assessments before the exam
• Full-length practice in 14 × 30-minute blocks completed
• Break plan and test-day logistics set

What comes next

After Step 1, most candidates move on to Step 2 CK. IMGs also work toward ECFMG Certification and the Match. See the Step 2 CK guide, the IMG pathway to US residency and, for the job market after training, Physician and Nurse Jobs Outlook in the USA. If you are still choosing a route into medicine, start with Medical School in the USA.