Louisiana Community Plan Pharmacy Prior Authorization Forms

Prior authorization is required for some services and medications. A current list of prior authorization services, medications and forms can be found below.

Uniform Prescription Drug Prior Authorization Form

As of January 1, 2019, the State of Louisiana requires all health care providers to use their state-specific form for prescription drug prior authorization requests.

Health care providers should entirely fill out and submit the completed form to the fax number listed on the form. Please include any additional documentation such as clinical notes, lab values, etc. that support your prior authorization request.

NOTE: Any prior authorization requests that aren't submitted using the Louisiana Uniform Prescription Drug Prior  Authorization Form will be canceled. We'll ask you to resubmit your request using the correct form. Please include any needed UnitedHealthcare Community Plan forms, listed below, in addition to the Louisiana Uniform Prescription Drug Prior Authorization Form. Please refer to the Louisiana website for the most updated information.

Looking for the medical benefit  version of this form?