- Prior authorization criteria (PDF)
- Hepatitis C prior authorization form (PDF)
- Revised hepatitis C treatment criteria (PDF)
- Synagis prior authorization criteria (PDF)
- Synagis prior authorization form (PDF)
- Opioid analgesic treatment worksheet (PDF)
Drugs requiring prior authorization (PA) or having any other restrictions are identified in the printable formulary (PDF) of the AmeriHealth Caritas Louisiana Formulary and through the searchable formulary.
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).
- Online PA request form
- Download and complete the Healthy Louisiana Pharmacy universal PA request form. Fax to: 855-452-9131
Prescribers may also request PA medications by calling the PerformRx Provider Services Help Desk at 800-684-5502.
For Prior Authorization forms for Specialty medication with "drug specific" criteria, use the prior authorization forms.
All forms need to be completed with required information, signed by the prescriber, and forwarded (by mail or fax) along with any supporting documentation to PerformRx.
200 Stevens Drive
Philadelphia, PA 19113
Prescribers may request copies of the criteria used to make the Prior Authorization determination by contacting the PerformRx Provider Services Help Desk at 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.