CurrentIndependent HealthPolicy N/A

Pharmacy Drug Prior Authorization Request Form Coverage Criteria

This document is a pharmacy prior authorization request form used by providers to request coverage for prescription drugs from Independent Health and to document clinical justification, prior therapies, and administration details.

Policy Summary

PayerIndependent Health

PolicyPharmacy Drug Prior Authorization Request Form Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must supply member and prescriber identifiers, drug details, prior formulary drugs tried with dates and reasons for failure, and MD signature/date when submitting prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1prior authorization form (single-page elements)

2sections listing prior formulary drugs tried

1contact phone block for pharmacy department

Coverage Criteria

The form does not list any explicit coverage exclusions. Providers should note, however, that a request can be denied or not processed if required information is missing or incomplete (for example, missing clinical justification, prior therapy history, or provider signature/date).

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests for non-formulary, specialty, or limited-access medications. Use this form to submit the clinical justification and complete member, prescriber, and drug details. Attach supporting clinical records as needed (e.g., progress notes, lab results).

Complete the entire form and include all requested fields to avoid processing delays.
Indicate if this is a renewal or an initial request; if renewal, provide the date therapy was initiated.
If administering provider is different from prescriber, indicate who will administer (MEMBER or PROVIDER).

Policy Summary

PayerIndependent Health

PolicyPharmacy Drug Prior Authorization Request Form Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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.

Step Therapy

Step Therapy Documentation

Document all formulary agents tried and reasons for failure to support step therapy exceptions. Include drug name, strength, dates tried, and specific clinical reason for discontinuation or inadequacy (e.g., lack of efficacy, adverse event, contraindication).

List each prior agent with Dates Tried and Reason for Failure.
If exceptions to step therapy are requested, provide clinical rationale and attach evidence (chart notes, test results).

Documentation Required

Required Submission Fields

Provide the following required fields on the submission form. Incomplete or missing fields may result in denial or delayed review.

Member identifiers: Member Name, DOB, Member ID number, Date of request.
Prescriber information: MD Name, MD NPI, MD Address, MD TIN, MD Fax Number, MD Phone Number, Contact Person and Phone Number.
Drug request details: Drug Requested (name, strength & form), Quantity Prescribed, Expected Duration, Directions for use, Diagnosis, Reason(s) drug is requested (clinical justification).
Administration info: Who will administer (MEMBER or PROVIDER), Is this a renewal (Yes/No) and if Yes, date drug was initiated.

Denial Risk

Incomplete Submission May Be Denied

Incomplete submissions lacking clinical justification, prior trial documentation, provider signature/date, or required member/prescriber identifiers may be denied. Ensure all sections are completed and supporting documents are attached.

Missing clinical rationale or documentation of prior therapies may result in denial for failure to meet step therapy or medical necessity criteria.
Unsigned forms or absent dates on signature lines can lead to return or denial of the request.
Provide contact information for follow-up to prevent processing delays.

Note

Submission Instructions & Contact

Complete the form fields exactly as shown and include MD signature and date. If you have questions or need to submit additional documents, contact the pharmacy department.

Form contact: Pharmacy Department (716) 631-2934 or (800) 247-1466 x531, Monday–Friday 8:00 am–5:00 pm.
Mail to: Independent Health Association Attn: Pharmacy Department 511 Farber Lakes Drive Buffalo, NY 14221.
Fax submissions as directed on the form; include all attachments and the completed 'Other Formulary Drugs tried' table with Dates Tried and Reason for Failure.
MD Signature and Date are required.

Step Therapy Documentation

Drug name	Dates tried	Reason for failure

Site of Care / Administration

Note

Specify administration site/person

Indicate on the form who will administer the medication by checking either MEMBER or PROVIDER in the "Who will administer this medication" field.

Select one: MEMBER or PROVIDER.

Definitions

Renewal

FieldRenewal

Prompt on formIs this a renewal? (YES / NO)

If renewal = YESDate drug was initiated

Appeal

FieldAppeal

Prompt on formIs this an appeal to a previously denied request? (YES / NO)

Required actionCheck YES or NO to indicate appeal status

Background

This form is used to request pharmacy coverage for a prescription medication and to document key information needed for prior authorization decisions. It collects member identifiers and prescriber details, the drug requested (name, strength, form), quantity, expected duration and directions, diagnosis, whether the request is a renewal and the date the drug was initiated if applicable, and who will administer the medication (member or provider).

The form also captures clinical justification and prior therapy history: providers must provide the reason(s) the drug is requested and may attach supporting documentation. There is a dedicated section to list other formulary drugs tried with dates and reasons for failure to support step therapy assessment.

Finally, the form requires the prescriber’s signature and date; contact information for the pharmacy department is provided for questions.