[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283901-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283901-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","louisiana-uniform-prescription-drug-prior-authorization-form-submission-sections","Louisiana Uniform Prescription Drug Prior Authorization Form - Submission Sections","","Louisiana Uniform Prescription Drug Prior Authorization Request Coversheet and form for submitting pharmacy prior authorization documentation to Louisiana health plans. Includes member plan selection, privacy and confidentiality notice for facsimile transmission, and addresses contact and pharmacy helpdesk information. Collects prescriber, patient, and requested prescription drug details, including diagnosis codes, dates, and supporting clinical data. Contains opioid-specific fields such as quantity limits, cumulative daily MME checks, and prescriber attestations.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/louisiana-uniform-prescription-drug-prior-authorization-form-submission-sections/283901/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/louisiana-uniform-prescription-drug-prior-authorization-form-submission-sections/283901.png","ImageObject",442,249,{"name":42,"@type":43},"Xiajie","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-27","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",15,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Which health plans can be selected on the coversheet for the prior authorization request?","Question",{"text":63,"@type":64},"The coversheet lists multiple Louisiana health plans, including Aetna Better Health of Louisiana, AmeriHealth Caritas Louisiana, Louisiana Legacy Medicaid (Fee-for-Service), Healthy Blue, LA Healthcare Connections, and United Healthcare.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information is required in the prescriber section?",{"text":68,"@type":64},"It collects the prescriber’s name, NPI or plan provider number, specialty, address, city, state, ZIP, phone, fax, office contact name, and contact phone.",{"name":70,"@type":61,"acceptedAnswer":71},"What additional checks are included for opioid medications in the form?",{"text":72,"@type":64},"For opioid medications only, it asks whether the requested quantity exceeds the allowed max quantity and whether cumulative daily MME exceeds the daily max, and it includes fields for prescriber attestations for short-acting and long-acting opioids.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283901,1789621756,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":80,"read_time":22},8814010472675,"https://avatar.qwps.com/avatar/WGlhamll","John Bel Edwards  \nGOVERNOR  \nRebekah E. Gee M.D., MPH  \nSECRETARY  \nState of Louisiana  \nLouisiana Department of Health  \nBureau of Health Services Financing  \nPRIOR AUTHORIZATION REQUEST COVERSHEET  \nPlease check the member’s appropriate health plan listed below.  \n􀂆 Aetna Better Health of Louisiana  \nPhone: 1-855-242-0802 Fax: 1-844-699-2889  \n[www.aetnabetterhealth.com/louisiana/providers/pharmacy](www.aetnabetterhealth.com/louisiana/providers/pharmacy)  \n􀂆 AmeriHealth Caritas Louisiana  \nPhone: 1-800-684-5502 Fax: 1-855-452-9131  \n[www.amerihealthcaritasla.com/pharmacy/index.aspx](www.amerihealthcaritasla.com/pharmacy/index.aspx)  \n􀂆 Fee-for-Service (FFS) Louisiana Legacy Medicaid  \nPhone: 1-866-730-4357 Fax: 1-866-797-2329  \n[www.lamedicaid.com](www.lamedicaid.com)  \n􀂆 Healthy Blue  \nPhone: 1-844-521-6942 Fax: 1-844-864-7865  \n[https://providers.healthybluela.com/la/pages/home.aspx](https://providers.healthybluela.com/la/pages/home.aspx)  \n􀂆 LA Healthcare Connections  \nPhone: 1-888-929-3790 Fax: 1-866-399-0929  \n[www.louisianahealthconnect.com/for-members/pharmacy-services/](www.louisianahealthconnect.com/for-members/pharmacy-services/)  \n􀂆 United Healthcare  \nPhone: 1-800-310-6826 Fax: 1-866-940-7328  \n[https://www.uhcprovider.com/en/health-plans-by-state/louisiana-health](https://www.uhcprovider.com/en/health-plans-by-state/louisiana-health)plans/la-comm-plan-home/la-cp-pharmacy.html  \nElectronic Prior Authorization: [https://provider.linkhealth.com/\\#/](https://provider.linkhealth.com/#/)  \nPRIVACY AND CONFIDENTIALITY WARNING  \nThis facsimile transmission may contain Protected Health Information, Individual Identifiable Health Information and other information which is protected by law. The information is intended only for the use of the intended recipient. If you are not the intended recipient, you are hereby notified that any review, disclosure/re-disclosure, copying, storing, distributing or the taking of action in reliance on the content of this facsimile transmission and any attachments thereto, is strictly prohibited. If you have received this facsimile transmission in error, please notify the sender immediately via telephone and destroy the contents of this facsimile transmission and its attachments.  \nPLEASE CALL IF YOU HAVE ANY PROBLEMS RECEIVING THIS FAXOR IF PAGES ARE MISSING.  \nBienville Building ▪  \n628 N. Fourth St. ▪ P.O. Box 91030 ▪ Baton Rouge, Louisiana 70821-9030 Pharmacy Helpdesk Phone: (800) 437-9101  \nAn Equal Opportunity Employer  \nLOUISIANA UNIFORM PRESCRIPTION DRUG PRIOR AUTHORIZATION FORM  \nSECTION I—SUBMISSION  \n\n| Submitted to: | Phone: | Fax: | Date: |\n| --- | --- | --- | --- |\n\nSECTION II―PRESCRIBER INFORMATION  \n\n| Last Name, First Name MI: |  | NPI\\# or Plan Provider \\#: | Specialty: |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Address: |  | City: |  |  | State: | ZIP Code: |\n| Phone: | Fax: | Office Contact Name: |  | Contact Phone: |  |  |\n\nSECTION III—PATIENT INFORMATION  \n\n| Last Name, First Name MI: |  | DOB: |  | Phone: |  |  | Male\u003Cbr>Other |  | | Female Unknown |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Address: |  |  | City: |  |  |  |  | State: | ZIP Code: |  |\n| Plan Name (if different from Section I): | Member or Medicaid ID \\#: |  |  | Plan Provider ID: |  |  |  |  |  |  |\n| Patient is currently a hospital inpatient getting ready for discharge?   Yes   No Date of Discharge: \u003Cbr>Patient is being discharged from a psychiatric facility?   Yes   No Date of Discharge: \u003Cbr>Patient is being discharged from a residential substance use facility?   Yes   No Date of Discharge:  Patient is a long-term care resident?   Yes   No If yes, name and phone number:  EPSDT Support Coordinator contact information, if applicable: |  |  |  |  |  |  |  |  |  |  |\n\nSECTION IV―PRESCRIPTION DRUG INFORMATION  \n\n| Requested Drug Name: |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Strength: | Dosage Form: | R","cbCaieLTM2zo949I","https://ap.wps.com/l/cbCaieLTM2zo949I","pdf",2048148,"English","# PRIOR AUTHORIZATION REQUEST COVERSHEET\n# SECTION I—SUBMISSION\n# SECTION II—PRESCRIBER INFORMATION\n# SECTION III—PATIENT INFORMATION\n# SECTION IV―PRESCRIPTION DRUG INFORMATION\n# SECTION V—PATIENT CLINICAL INFORMATION\n# SECTION VI—OPIOID MEDICATIONS ONLY","[{\"question\":\"Which health plans can be selected on the coversheet for the prior authorization request?\",\"answer\":\"The coversheet lists multiple Louisiana health plans, including Aetna Better Health of Louisiana, AmeriHealth Caritas Louisiana, Louisiana Legacy Medicaid (Fee-for-Service), Healthy Blue, LA Healthcare Connections, and United Healthcare.\"},{\"question\":\"What information is required in the prescriber section?\",\"answer\":\"It collects the prescriber’s name, NPI or plan provider number, specialty, address, city, state, ZIP, phone, fax, office contact name, and contact phone.\"},{\"question\":\"What additional checks are included for opioid medications in the form?\",\"answer\":\"For opioid medications only, it asks whether the requested quantity exceeds the allowed max quantity and whether cumulative daily MME exceeds the daily max, and it includes fields for prescriber attestations for short-acting and long-acting opioids.\"}]","Louisiana Uniform Prescription Drug Prior Authorization Form - Submission Sections | PDF"]