Effective January 1st 2019, please submit requests for controlled substances using the new Uniform Prescription Drug Prior Authorization Form.  Please review the pharmacy authorization guidelines to ensure you have submitted all guideline requirements.

Louisiana Uniform Prescription Drug Prior Authorization Form 


The Louisiana Department of Health Resources

The Department would like to share our new “Opioid” web page. There are many great resources posted here:

Don’t forget about the Naloxone Standing Order:

April 2017 Provider Update includes Morphine Equivalent Dose information:

Formulary drug list

The formulary is a list of drugs chosen by Louisiana Department of Health's Pharmacy P & T Committee and administered by Aetna Better Health of Louisiana.  Drugs are listed as preferred and non-preferred.  All non-preferred drugs are required to follow the prior authorization process.

There is a subset of drugs not listed on the Louisiana Medicaid Single PDL which may be available for coverage.  These drugs typically do not require a prior authorization.  Generic substitution is mandated by the state unless a drug is on the preferred drug list as a Brand Name product.  Clinical edits, such as quantity limits and age restrictions, may apply to some drug categories.

Members must fill their prescriptions at an Aetna Better Health of Louisiana network pharmacy and follow other plan rules.

Please review the formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Louisiana patient.

Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations)

If your members take medicine for an ongoing health condition, they can have their medicines mailed to their home. Aetna Better Health works with a company called CVS Health to provide this service, at no cost to our members.

If they choose this option, their medicine comes right to their door. There are other benefits to home delivery:

  • Pharmacists check each order for safety.
  • Members can order refills by mail, by phone, online, or they can sign up for automatic refills.
  • Members can talk with pharmacists by phone at any time 24 hours a day, 7 days a week.

 Members can sign up for this service in one of three ways. They can:

  • Call CVS Health toll-free at 1-855-271-6603 Monday to Friday between 8 a.m. and 8 p.m.,. CVS representatives will help your member sign up for home delivery. (As you are the provider, CVS will call you to get the prescription.)
  • Go to CVS website. Then, log in and sign up for ReadyFill. Again, CVS Health will contact you, the provider, to get a prescription.
  • Request a prescription from you for a 90-day supply with up to one year of refills. The member will then complete the mail- order services form and mail it to CVS Health along with the prescription.

CVS Health Mail Order Service Form English / Spanish

Aetna Better Health of Louisiana also covers certain over-the-counter drugs if they are on our list. Some of these may have rules about how they can be covered. If the rules for that drug are met, we will cover the drug. Over-the-counter drugs must have a prescription for them to be covered at no cost to our members.

Effective May 1st, 2019, Aetna Better Health® of Louisiana adheres to the Healthy LA PDL clinical criteria to make decisions when you send in a request for a drug on the formulary/PDL that needs a review prior to being dispensed. 

To access clinical criteria, click here to be taken to the Healthy LA Pharmacy clinical criteria.


Additional criteria found below will also apply as of May 1st, 2019.

Brand Name Medications

Compounds  (effective 12.02.2019)

Diabetic Testing Supplies  (effective 12.02.2019)

Quantity Level Limits



Algorithms December 2019

Hep C LA Elimination Plan

Hep C Policy Criteria (Authorized Generic(AG) Epclusa Preferred)

State PDL Page 34 Hepatitis C Agents

To quickly find a prior authorization form, click CTRL F on your keyboard and type in the form name.  

Louisiana Uniform Prescription Drug Prior Authorization Form  


Hepatitis C DAA Request Form 









We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591


Group: RX8834

The Prescription Monitoring Program (PMP)  is accessed by utilizing the Louisiana Board of Pharmacy.

CVS Health Specialty Pharmacy is a pharmacy that offers medications for a variety of conditions, such as cancer, hemophilia, immune deficiency, multiple sclerosis and rheumatoid arthritis. These specialty medications are not often available at local pharmacies. Specialty medications require service authorization before they can be filled and delivered. Providers can call 1-855-242-0802 to request prior authorization, or complete the applicable prior authorization form and fax to 1-844-699-2889.

Specialty medications can be delivered to the provider’s office, member’s home, or other location as requested.

Certain drugs on the formulary have quantity limits (QLLs). The QLLs are established based on FDA-approved dosing levels and nationally- established, recognized guidelines pertaining to the treatment and management of the condition being treated.

To request an override for the quantity limit, please fax the correct pharmacy Prior Authorization request form to 1-844-699-2889. You can include any medical records that will support your request.

Pharmacy & Therapeutics Committee Meetings

10000 Perkins Rowe, Suite 500, Baton Rouge, LA. 70810, 5:30 – 7PM.  ABHLA complies with Open Meetings Laws.

Dates:  2020 P&T Committee Meeting (Tentative)     

      • 1st Biannual Meeting, Tuesday, June 23, 2020 
      • 2nd Biannual Meeting, Tuesday, October 13, 2020 

Due to limited seating, please RSVP Vanessa Smith at


*Go to the central elevator and come to the 5th floor. If the door is not open, please call (225) 315-9561 to gain access.*

Meeting agendas

June 23, 2020

December 12, 2018

February 11, 2019

December 10, 2019


If you have any questions contact:

Vanessa N. Smith, DPh

Director of Pharmacy

(504) 667-4544 Office



Pharmacy & Therapeutics Committee Guidelines

PT Committee Meeting Speakers Request Form

Special member support programs

Q2 DUR Education - CBD Oil and Drug Interactions

Q1 DUR Education - Antidepressants and Breastfeeding