2018-73: New Uniform Medicaid Prescription Drug Prior Authorization Form for 2019
Date: 12/28/18
Effective January 1, 2019, the Louisiana Medicaid fee-for-service (FFS) pharmacy program and Medicaid’s five managed care organizations (MCOs) will require prescribers to use the Louisiana Uniform Prescription Drug Prior Authorization Form (PDF).
Use of the form is mandated through Act 423 of the 2018 Louisiana Legislative Regular Session and impacts all insurance payors in the state, including Medicaid. According to the Act, “a prescriber or pharmacy required to obtain prior authorization from a third party payor shall complete the Louisiana Uniform Prescription Drug Prior Authorization Form.” Prior authorization of specialty drugs could require use of a different form in order to obtain the necessary clinical information.
The following guidance applies to use of the uniform prior authorization form:
- Prescribers shall complete the form in full and fax to the appropriate Medicaid MCO or the FFS pharmacy prior authorization provider. Fax numbers listed below, and on the form.
- Use of the form is a legal requirement and a prior authorization request could be denied if not submitted on the proper form.
- To obtain necessary prior authorization processing, the following therapeutic classes shall be considered specialty drugs for Medicaid, but ONLY for prior authorization purposes. This list is subject to change:
- Hepatitis C Virus (HCV) Direct-Acting Antiviral (DAA) agents
- Palivizumab (Synagis®)
- Multiple sclerosis agents o Respiratory monoclonal antibody agents: benralizumab (Fasenra®), dupilumab (Dupixent®), mepolizumab (Nucala®), omalizumab (Xolair®), and reslizumab (Cinqair®)
- Growth Hormones
Questions about pharmacy claims billing should be routed to the appropriate pharmacy helpdesk, as noted below.
| Health Plan | PBM | Phone Number | Fax Number |
|---|---|---|---|
| Aetna Better Health of Louisiana | CVS Health | (855) 242-0802 | (844) 699-2889 |
| AmeriHealth Caritas of Louisiana | PerformRx | (800) 684-5502 | (855) 452-9131 |
| Fee-for-Service Louisiana Legacy Medicaid | DXC Technology | (800) 730-4357 | (866) 797-2329 |
| Healthy Blue | Express Scripts | (844) 521-6942 | (844) 864-7865 |
| Louisiana Healthcare Connections | CVS Caremark | (888) 929-3790 | (866) 399-0929 |
| UnitedHealthCare | Optum Rx | (800) 310-6826 | (866) 940-7328 |