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Pharmacy prior authorization (PA)

When a medication isn't on our preferred drug list (PDL), or has a utilization management requirement, you’ll want to request pharmacy PA. Take a minute to review our current guidelines.

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Pharmacy PA guidelines

Pharmacy PA guidelines

When you request prior authorization (PA) for a drug on the PDL, we use the Healthy Louisiana PDL clinical criteria  to make decisions. 


Healthy Louisiana guidelines and policies


Healthy Louisiana pharmacy clinical criteria (PDF)


Choose the “Criteria” link under each drug class column and to the left of the drug column.


Diabetic test strips and lancets quantity limits: January 1, 2021 (PDF)


Diabetic testing supplies supplement: December, 2020 (PDF)


Aetna Better Health guidelines and policies


Compounds coverage policy/guideline: December 2, 2019 (PDF)


Quantity level limit guideline: August 18, 2020 (PDF)

Electronic PA (ePA)

Electronic PA (ePA)

You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds®  and Surescripts to provide a new way to request a pharmacy PA with our ePA program.


With ePA, you can look forward to saving time with:


  • Less paperwork 

  • Fewer phone calls and faxes

  • Quicker determinations 

  • Safe and secure HIPAA-compliant submitted requests

  • Easy upload of clinical documents

Enroll now

Getting started with ePA is free and easy. You’ll need this info to enroll:


  • BIN: 610591
  • GRP: RX8834
  • PCN: ADV 


You can enroll two different ways:

Other ways to request PA


If you don’t want to enroll in ePA, you can request PA:

By phone

You can request PA by calling us at 1-855-242-0802 (TTY: 711).

By fax

Check “Request forms” in the next section to find the right form. Then, fax it with any supporting documentation for a medical necessity review to 1-844-699-2889.

Request forms

If you don’t see the right form in the list, you can use the uniform prescription drug PA form (PDF). Otherwise, check for the drug class or drug name that matches your needs:

Spinraza® is a registered trademark of Biogen.

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