- Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) prior authorization criteria (PDF)
- AmeriHealth Caritas Louisiana non-PDL prior authorization criteria (PDF)
- Hepatitis C prior authorization form (PDF)
- Synagis prior authorization form (PDF)
Drugs requiring prior authorization (PA) or having any other restrictions are identified in the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF). A subset of drugs may be subject to additional edits — that criteria can be found in the AmeriHealth Caritas Louisiana non-PDL prior authorization criteria (PDF).
The prescriber must complete, sign, and submit a request for prior authorization or an override of a drug restriction on behalf of a member. Requests from pharmacists are not accepted, except to validate a member's historical drug use for purposes of grandfathering certain medications.
Use an online PA request form to request an override of any restriction accompanying a drug listed in the print formulary (including prior authorization).
Prescribers may also request PA medications by calling the PerformRx℠ Provider Services Help Desk at 1‑800‑684‑5502.
Prescribers may request copies of the criteria used to make the prior authorization determination by contacting the PerformRx Provider Services Help Desk at 1‑800‑684‑5502. We will post drug specific criteria to the pharmacy section of the website shortly.
In most cases where the prescribing health care professional/provider has not obtained prior authorization, members will receive a three-day emergency supply of the medication.