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Specialty Medication Authorization Template

Four documents and three sheets, splitting the wait into the days the payer owns and the days your own clock sat dark.

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Status Tracking

Elapsed time split into the days you own and the days the plan owns

One row per request. The two date columns in the middle are the whole point: an exception filed is not an exception running, and the gap between those two dates belongs to the practice.

Why "filed" is not the start date

For a Part D exceptions request the plan's decision window runs from receipt of the prescriber's supporting statement, not from receipt of the request. File on Monday, get the statement signed on Friday, and four days have gone by with the portal showing pending and the plan owing nothing yet.

The three routes, in the order to check them

Lookback defence first, because it argues the requirement never attached and there is nothing for a reviewer to weigh. Exception second. Standard prior authorization only where neither applies. Practices that skip the first step file exceptions they did not need.

The column that catches a late plan

Plan deadline is computed, not typed. Inside fourteen days it is the statement date plus 72 hours. Past fourteen days it is the fourteenth day plus 72 hours, which is a worse deadline and one the practice chose by being slow.

A specialty prior authorization that has been filed is not a specialty prior authorization that is running. For a Part D exceptions request the plan must decide no later than 72 hours after receipt of the physician's or other prescriber's supporting statement, and not from receipt of the request. So the days between filing and getting that statement signed are days nobody owes anything, and the portal says pending throughout, which is why a practice can be four days into a wait it believes the plan is causing.

That gap is a column, and this pack makes it one. Days the clock was dark is the statement date minus the filing date, sitting beside payer days, which is the decision date minus the statement date. Two numbers that a single elapsed-days figure hides completely. There is a threshold in the same rule worth knowing before it passes: once fourteen calendar days go by without a statement, the deadline detaches from the statement and fixes to the calendar instead.

Before writing any exception, check whether the requirement attaches at all. A Medicare Advantage plan running step therapy for Part B drugs must apply step therapy only to new administrations, using at least a 365 day lookback period. A patient dosed inside that window is not a new administration, so there is nothing for a reviewer to weigh. The register carries that date for exactly that reason. At Thornbury Rheumatology two such requests closed in five and four days against a 6.5 day median. Both routes still end at a letter a prescriber signs.

Twenty-nine of the thirty-nine days were ours, not the plan's

The dark-clock split per request, the register that shows why the same drug takes a different route under a different benefit, and the second clock that actually medicates the patient.

Status Tracking

Illustrative figures for a fictional practice, Thornbury Rheumatology, 2026 Q1. Six specialty requests. Three took the exceptions path and are the only three where the dark-clock column has anything in it.

RequestBenefitRoute chosenLast administrationFiledSupporting statement inDays the clock was darkDecisionPayer days after statementPlan deadline under the ruleTotal days
           
           
RequestBenefitRouteLast admin.FiledStatement inDark daysDecisionPayer daysPlan deadlineLate byTotal
SPX-201MA Part BLookback defence118 days01-08Not required001-13n/aMA determination 5
SPX-207Part DExceptionNone recorded01-1501-17201-20301-2005
SPX-214MA Part BException412 days02-0202-131102-163MA Part B rule 14
SPX-219Commercial pharmacyStandard prior auth.n/a02-11Not required002-19n/aPlan policy 8
SPX-226Part DExceptionNone recorded02-2403-121603-16403-13320
SPX-233MA Part BLookback defence61 days03-09Not required003-13n/aMA determination 4
Three exceptions, totalled     29 10 339
Median across all six          6.5

Of the 39 days the three exceptions took, 29 were dark and 10 were the plan's. The plan answered in three days twice and four days once, so it was never the bottleneck. SPX-226 is the row worth reading twice: sixteen dark days pushed the statement past the fourteenth day, which moved the deadline off the statement date and onto the calendar. The plan then owed a decision by 13 March and produced one on 16 March. Three days genuinely late, on a deadline that only existed because the practice was eleven days later still.

Requirement Register

One row per drug and payer, not one per drug. The same molecule under the same insurer takes a different route depending on which benefit pays for it, which is why the benefit column comes second.

DrugBenefitPayerStep therapy attachesRequired agentsLookback publishedLast administration recordedLookback defenceException pathStatement requiredBridge doses
Drug AMA Part BSummit AdvantageYesTwo conventional agents365Every requestInside 365 daysPart B step therapy exceptionYes2
Drug APart DHorizon MedicaidYesTwo conventional agentsNot publishedNot requiredNoPart D exceptions processYes2
Drug BPart DSummit AdvantageYesOne conventional agentNot publishedNot requiredNoPart D exceptions processYes2
Drug CCommercial pharmacyRidgeline HealthNoNonen/aNot requiredn/aStandard prior authorizationNo0
Drug DMA Part BSummit AdvantageYesOne biosimilar365Every requestInside 365 daysPart B step therapy exceptionYes1
Drug DCommercial medicalCascade MutualYesOne biosimilarNot publishedNot requiredNoPlan exception processYes1

Drug A appears twice and Drug D appears twice, and in each pair the lookback column differs. Under Medicare Advantage the lookback is a published number with a floor in regulation, so a recorded prior administration inside it is a defence the practice can state. Under the other benefits the same plan publishes nothing and does not ask, so the same clinical fact buys nothing and the exception is the only route. Two rows carry no assistance bridge because the programme excludes federally insured patients, and a coordinator who does not read that column before promising a bridge dose has promised something that will be refused.

Assistance Programme Register

The second clock, tracked on its own sheet because it runs independently of the first. The column that matters is the last one: whether the coverage decision landed before or after the patient was actually dosed.

RequestDrugProgrammeTypeAppliedBridge approvedFirst doseFiling to first doseBridge dosesDays of therapy coveredDecision vs first dose
SPX-201Drug ANot needed   01-157002 days before
SPX-207Drug BManufacturer bridgeBridge doses01-1501-1701-1942561 day after
SPX-214Drug AManufacturer bridgeBridge doses02-0202-0502-06412810 days after
SPX-219Drug CCopay assistance cardCopay reduction02-1102-1602-2312004 days before
SPX-226Drug BNone applied for Nobody opened it 03-1923003 days before
SPX-233Drug DNot needed   03-178004 days before
Totals       384 
Mean filing to first dose where a programme was opened Three requests    6.7   

SPX-214 is the case for keeping this sheet. The coverage decision took fourteen days and the patient was dosed on day four, ten days before anyone knew whether the plan would pay, on a single bridge dose covering 28 days of therapy. SPX-226 is the same drug and the same payer with nobody on the second track, and the first dose was day 23, three days after approval, because without a bridge the first dose is the decision plus fulfilment. Twenty-three against a mean of 6.7 across the three where somebody opened it. The two rows reading "not needed" are honest, not lazy: coverage resolved in five days and four days respectively, so there was no gap to bridge.

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What's in the pack

01

How the Two Clocks Work

The method note. Why the payer clock starts at the supporting statement, what changes at day fourteen, and why the assistance clock is tracked on a separate sheet rather than a status column.

02

Requirement Register

One row per drug and payer, carrying the published lookback, whether a prior administration is recorded, and whether the assistance programme excludes federally insured patients. Services with no formulary behind them belong in the prior authorization pack instead.

03

Status Tracking

Dark days and payer days in separate columns, with the plan's deadline computed from whichever branch of the rule applies rather than typed in by hand.

04

Authorization Request

The standard submission, structured so the clinical narrative and the plan's own criteria language sit in adjacent sections instead of being interleaved into one argument.

05

Step Therapy Exception Request

The exception path, opening with the lookback question so a request that never needed to be an exception gets caught before it is written rather than after it is filed.

06

Patient Communication

Two letters, one for a coverage determination that is open and one for a bridge dose being arranged, both stating what the patient does next rather than what the practice is waiting on.

07

Assistance Programme Register

Applied, bridge approved, first dose and days of therapy covered, plus whether the coverage decision landed before or after the patient was dosed. Renewal owner and expiry sit on the same row.

08

Where a request goes next

The plan criteria behind a row get read by the payer policy criteria summary. A denial that needs a clinician on the phone routes to peer-to-peer review preparation.

How to use it

  1. 1

    Open in River, or download it

    Open the pack in River and let the agent build the requirement register from your formulary and plan policies, or download the blank Word and CSV files instantly and start with one drug.

  2. 2

    Build the register by drug and payer, not by drug

    The same molecule takes different routes under Part B, Part D and a commercial pharmacy benefit. One row per pair is more rows and far fewer wrong submissions.

  3. 3

    Record the last administration date on every request

    It is the only field that can make step therapy not attach. Practices that skip it write exceptions for requests where a recorded prior dose was already the answer.

  4. 4

    Open the second track the same day you file

    Not when the denial arrives. In the worked quarter the requests with an assistance programme open reached a first dose in a mean of 6.7 days against 23 for the one without.

Frequently asked questions

Is this template free?

Yes. The four documents and three sheets download as Word and CSV files with no signup and no card. "Edit with AI" is the optional path for practices that want the requirement register built from their own formulary and plan policies. The rest of the library is at the template library.

What format are the downloaded files?

Word documents for the method note, the authorization request, the step therapy exception request and the patient letters, plus CSV for the three registers, zipped into one file. They open in Word, Pages, Google Docs, Excel, Numbers and Sheets with nothing to convert.

Why track dark days separately from payer days?

Because they have different owners and only one is fixable by the practice. In the worked quarter the three exceptions took 39 days between them, of which 29 were the wait for a prescriber's statement and 10 were the plan. The plan never took more than four days.

What actually happens at day fourteen?

The deadline changes shape. Inside fourteen days it is 72 hours from the statement, tied to an event the practice controls. Past fourteen days it fixes to the fourteenth day plus 72 hours instead. SPX-226 in the worked quarter crossed it and the decision then arrived three days late.

Is the lookback defence different from an exception?

Yes, and it is faster. An exception asks a reviewer to weigh a clinical argument. The lookback argues the step therapy requirement does not attach, because the drug is not a new administration. The prescriber still provides the supporting statement where an exception is the route.

Does this pack decide whether a drug will be covered?

No. It cannot, and nothing here predicts a plan's decision or weighs whether a medication is appropriate. Those are the prescriber's judgement and the plan's determination. The pack organises the paperwork around both, and tracks which of two administrative clocks is holding up the patient.

What if the patient cannot wait for either clock?

That is a clinical call and it routes to the prescriber immediately, not through this workspace. The pack's contribution is the bridge column: knowing before you ask whether the programme covers federally insured patients, so nobody promises a dose that will be refused.

Written by

Chandler Supple

Co-founder & CEO, River

Chandler has spent six years working in AI, building tools for millions of users and Fortune 100 companies along the way. He now leads River as co-founder and CEO.

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Reviewed by

Brian Joseff, Co-founder, River

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Find out how many of your waiting days are actually yours

Send a quarter of specialty requests however they exist, a portal export or a spreadsheet. The first thing back is elapsed time split into dark days and payer days per request.

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