Louisiana Uniform Prescription Drug Prior Authorization Form (Effective
January 1, 2019)
(PDF Format) |
This page contains the pharmacy Prior Authorization (PA) form for Fee-for-Service Medicaid and MCO plans. |
RXPA Instructions
(PDF Format)
(last modified 5/28/02) |
Instructions for Louisiana Medicaid Pharmacy Benefits Management Prior Authorization Program. |
Request for Palivizumab Clinical Authorization Form and Fax Coversheet
(PDF Format) |
This page contains the form for Palivizumab Clinical Authorization requests. |
Palivizumab Request for Reconsideration
(PDF Format) |
This page contains the form for Palivizumab Request for Reconsideration. |
Appendix D. Retroactive Eligibility Process for RxPA
(PDF Format)
(last modified 3/26/03) |
Details the information required to review retroactive eligibility. |
RXPA PPN File
(Zip File)
(updated daily) |
Prescribing Provider File sorted by provider name. |
RXPA PPN File
(Zip File)
(updated daily) |
Prescribing Provider File sorted by provider type. |
Medicaid Provider Preferred Drug List (PDL) Letter
(PDF Format) |
Letter to Medicaid Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List. |
Louisiana Medicaid Single Preferred Drug List
(PDF Format)
(Effective Date 10/1/19) |
Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL).
The listing includes preferred drugs and those drugs requiring prior authorization. |
| RxPA Letter Archives |
This page contains older letters sent to Prescribing and Pharmacy Providers detailing the progress of the RxPA Program. |
| Pharmacy Preferred Drug List (PDL) Archives |
This page contains older RXPA Informational letters and PDLs. |