CurrentIndependent HealthPolicy N/A

Request for Pharmacy Drug Authorization (Prior Authorization Form)

This document is the payer's standardized form for providers to request prior authorization or renewal of a pharmacy drug for a member of Independent Health. It governs information submission requirements and contact channels for pharmacy authorization requests.

Policy Summary

PayerIndependent Health

PolicyRequest for Pharmacy Drug Authorization (prior authorization form)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed request form to Independent Health Pharmacy Department via fax or mail and contact the pharmacy department for questions at the listed phone numbers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3document pages/chunks parsed

2contact phone numbers listed

3fax numbers listed for submission

1form title

Provider Submission & Documentation Requirements

Prior Authorization

Submission and Contact

Submit the completed Request for Pharmacy Drug Authorization form to Independent Health Pharmacy Department. Form may be mailed to: Independent Health Association Attn: Pharmacy Department 511 Farber Lakes Drive Buffalo, NY 14221, or faxed to: (716) 631-9636, (716) 631-0149, or (800) 273-7397. For questions, contact the pharmacy department at (716) 631-2934 or (800) 247-1466 x5311 between 8:00 am and 5:00 pm Monday - Friday.

Mail: Independent Health Association, Attn: Pharmacy Department, 511 Farber Lakes Drive, Buffalo, NY 14221
Fax: (716) 631-9636; (716) 631-0149; (800) 273-7397
Phone (questions): (716) 631-2934 or (800) 247-1466 x5311, Mon–Fri 8:00 am–5:00 pm

Step Therapy

Step Therapy Documentation

Provide documentation of prior trials of formulary alternatives, including drug names, exact dates tried, and specific clinical reason(s) each therapy failed or was not tolerated. This information supports step therapy or failure-to-treat requirements.

Policy Summary

PayerIndependent Health

PolicyRequest for Pharmacy Drug Authorization (prior authorization form)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed request form to Independent Health Pharmacy Department via fax or mail and contact the pharmacy department for questions at the listed phone numbers.

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 Submission Elements

Include complete member, prescriber, and drug information on the submission to allow processing. Incomplete or missing elements may delay or prevent authorization.

Member name, DOB, and member ID number
Date of request
Prescriber name, NPI, address, TIN, phone and fax numbers, contact person and contact phone
Drug requested: name, strength, form, quantity prescribed, expected duration, and directions for use
Diagnosis and indication for therapy
Is this a renewal? If yes, provide date drug was initiated
Who will administer the medication (member or provider)
Reason(s) drug is requested with supporting clinical information
MD signature and date

Denial Risk

Incomplete Submission

Incomplete submissions — for example, missing member identifiers, prescriber signature, required clinical information (including reasons prior therapies failed), or missing drug details (name, strength, quantity, directions) — may not be processed and will delay authorization. Ensure all required fields and supporting documentation are provided; you may attach additional records as needed.

Missing member name, DOB, or member ID can prevent processing
Absent MD signature or date will invalidate the request
Omitted details about prior therapies or reasons for failure may result in denial for not meeting step therapy requirements
Incomplete drug information (strength, form, quantity, directions) may delay review

Form Purpose & Scope

This form is an administrative Request for Pharmacy Drug Authorization used by providers to request initial or renewal prior authorization for pharmacy medications for Independent Health members. It collects member identifiers (name, DOB, member ID), prescriber information (MD name, NPI, address, TIN, phone, fax), and the clinical rationale for the request, including the drug requested (name, strength, form), quantity, expected duration, directions for use, diagnosis, and whether the request is a renewal with the date the drug was initiated.

The form specifically asks for prior treatment history to support coverage decisions: providers must document other formulary drugs tried, dates tried, and reason(s) for failure. It also asks who will administer the medication (Member or Provider) and requires the MD signature and date to complete the submission.

Renewal / Continuation Requirements

inv-07: Renewal Requirements

For renewals

Renewal submission requirements: If this request is a renewal, the provider must indicate YES, provide the date the drug was initiated, and submit supporting clinical information documenting ongoing need and response to therapy.

Include prior treatment history and reasons for change or continuation.

Prior therapy documentation: Provide documentation of other formulary drugs tried with dates tried and reason(s) for failure to demonstrate need for continued therapy or exception to step therapy requirements.

Use the 'Other Formulary Drugs tried' section to list each agent, dates tried, and reason for failure.

Drug Name	Dates Tried	Reason for Failure
[Enter drug name]	[Enter dates tried]	[Enter reason for failure]
[Enter drug name]	[Enter dates tried]	[Enter reason for failure]
[Enter drug name]	[Enter dates tried]	[Enter reason for failure]

OpenPayer

Request for Pharmacy Drug Authorization (Prior Authorization Form)

Provider Submission & Documentation Requirements

Form Purpose & Scope

Initial Authorization Criteria

Renewal / Continuation Requirements

Step Therapy Trials & Documentation

Administration / Site of Care