Louisiana Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Louisiana Medicaid prior authorization form is used when a medical professional wishes to request coverage for a prescription that is not normally covered by Medicaid because is not on the Preferred Drug List (PDL). In the State of Louisiana, Medicaid is handled by Healthy Louisiana, the department of health’s program to expand healthcare coverage for low-income individuals. On this webpage, you can download a PDF version of this form and fill it out by using either Adobe Acrobat or Microsoft Word. For more information on prior authorization or to make a prior authorization request by phone, call the number provided immediately below this paragraph.

Phone – 1 (800) 488-6334

Preferred Drug List (PDL) – List of pre-approved drugs by the State

How to Write

Step 1 – Download the “Healthy Louisiana Pharmacy Prior Authorization Form” and open it with Adobe Acrobat or Microsoft Word.

Step 2 – Use the checkboxes to indicate any healthcare providers which your patient is a member of.

Step 3 – In the “Member Information” section, provide your patient’s full name, date of birth, gender, height, weight, complete address, phone number, and policy ID number.

Step 4 – Next, in “Prescriber Information,” enter your practice name, specialty, your practice NPI number, your name, NPI number, DEA/License number, the complete address of your practice, and your associated phone number and fax number.

Step 5 – In the “Medication Information” section, first select whether this is an expedited request or not. Then you will need to provide all of the following information regarding your request:

  • Drug name, quantity, and strength
  • Directions for use
  • Dispense as written (Y/N)
  • Substitution permitted (Y/N)
  • Number of refills
  • Currently on this medication (Y/N)
  • Other medications tried to treat this condition (with dates)
  • Other current medications
  • Reason for discontinuation of tried therapies
  • Diagnosis/Indication and ICD diagnosis code

Beneath this, you will need to describe your justification for making this request in the indicated space. If you are going to attach additional documents to this form, check the box marked “Included lab results.” If the patient has any drug allergies and/or has an EPSDT Support Coordinator, enter this information into the indicated fields.

Step 6 – Beneath “Pharmacy Information,” supply the pharmacy name, phone number, and fax number.

Step 7 – Type the date and print your form. Once printed, sign your name by hand where indicated and fax your request to the appropriate directory for review.