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Louisiana Medicaid Prior (Rx) Authorization Form

Louisiana Medicaid prior authorization form is used by a medical professional to request coverage for a prescribed medication that is not on the state's preferred drug list (PDL). A physician must submit this form and a medical justification to the Department of Health in order for a non-preferred drug to be covered by the state's Medicaid program.
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Phone – 1 (800) 488-6334

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