Louisiana Department of Health

Bureau of Health Services Financing



DATE:            December 14, 2018

TO:                 All Louisiana Medicaid Prescribing Provider and Pharmacists

SUBJECT:     Louisiana Medicaid Fee for Service (FFS) and Managed Care Organizations (MCOs) Pharmacy Implementation of Louisiana Uniform Prescription Drug Prior Authorization (PA) Form

Effective January 1, 2019, the Louisiana Medicaid Fee for Service Pharmacy Program and five Managed Care Organizations (Aetna, AmeriHealth Caritas, Healthy Blue, Louisiana Healthcare Connections, and United Healthcare) will require all prescribers to use the Louisiana Uniform Prescription Drug Prior Authorization Form. In accordance with Act 423 of the 2018 Legislature, “a prescriber or pharmacy required to obtain prior authorization from a third party payor shall complete the Louisiana Uniform Prescription Drug Prior Authorization Form or its electronic equivalent.” Prior authorization of specialty drugs could require a different form in order to maintain the necessary information.

 The following specifications apply with the implementation of the Louisiana Uniform Prescription Drug Prior Authorization Form when submitting pharmacy claims to Medicaid FFS and MCOs.

  • Prescribers shall complete in full and fax the Louisiana Uniform Prescription Drug Prior Authorization Form to the appropriate Medicaid MCO or FFS pharmacy prior authorization
  • The use of the form is a legal requirement and your PA could be denied if the form is not
  • In order to obtain necessary prior authorization processing, the following therapeutic classes shall be considered specialty drugs for Medicaid only prior authorization purposes: Hepatitis C Virus (HCV) Direct-Acting Antiviral (DAA) agents, Palivizumab (Synagis®), multiple sclerosis, Omalizumab (Xolair®) and other monoclonal antibody agents, and Growth Hormones. This is subject to change.

If you have questions about the content of this memo, you may contact the FFS pharmacy help desk by phone at (800) 437-9101.

 If you have questions about pharmacy claims billing, you may contact the appropriate plan at their pharmacy help desk listed in the chart.

 CLICK HERE to  access the fax coversheet and PA Form

Healthcare Provider

Pharmacy Help Desk

Pharmacy Help Desk Phone Number


CVS Health

(855) 364-2977

AmeriHealth Caritas


(800) 684-5502

Fee for Service

DXC Technology

(800) 648-0790

Healthy Blue

Express Scripts

(844) 367-6111

Louisiana Healthcare Connections

CVS Caremark

(800) 311-0543

United Healthcare


(866) 328-3108


Please forward this notice to other providers to assist with notification. Your continued cooperation and support of the Louisiana Medicaid Program efforts to coordinate care and improve health are greatly appreciated.

Pin It on Pinterest

Share This