Prior Authorization

• Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) prior authorization criteria (PDF)
• AmeriHealth Caritas Louisiana non-PDL prior authorization criteria (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). The criteria for select provider-administered drugs 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. Prior authorization requests are to be submitted to PerformRx.

• Phone: 1-800-684-5502
• Fax: 1-855-452-9131

How to submit a request for prior authorization

To submit electronically, please submit an electronic prior authorization (ePA) through your electronic health record (EHR) tool software, or you can submit through any of the following online portals:

• CoverMyMeds
• SureScripts

All written requests for medications must be made using the Louisiana uniform prescription drug PA request form (PDF).

Prescribers may request copies of the criteria used to make the prior authorization determination by contacting PerformRx Provider Services Help Desk at 1-800-684-5502. 

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.