RXPA Forms or Files Description
Louisiana Uniform Prescription Drug Prior Authorization Form (Effective January 1, 2019)
(PDF Format)
This page contains the pharmacy Prior Authorization (PA) form for Fee-for-Service Medicaid and MCO plans.
RXPA Instructions
(PDF Format)
(last modified 5/28/02)
Instructions for Louisiana Medicaid Pharmacy Benefits Management Prior Authorization Program.
Request for Palivizumab Clinical Authorization
(PDF Format)
This page contains the form for Palivizumab Clinical Authorization requests.
Palivizumab Request for Reconsideration
(PDF Format)
This page contains the form for Palivizumab Request for Reconsideration.
Appendix D. Retroactive Eligibility Process for RxPA
(PDF Format)
(last modified 3/26/03)
Details the information required to review retroactive eligibility.
RXPA PPN File
(Zip File)
(updated daily)
Prescribing Provider File sorted by provider name.
RXPA PPN File
(Zip File)
(updated daily)
Prescribing Provider File sorted by provider type.
Medicaid Provider Preferred Drug List (PDL) Letter
(PDF Format)
Letter to Medicaid Providers detailing the progress of the RxPA Program and the most current version of the Preferred Drug List.
Louisiana Medicaid Single Preferred Drug List
(PDF Format)

(Effective Date 10/1/19)
Complete, most current listing of drugs on the Medicaid Prior Authorization (PA Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization.
RxPA Letter Archives This page contains older letters sent to Prescribing and Pharmacy Providers detailing the progress of the RxPA Program.
Pharmacy Preferred Drug List (PDL) Archives This page contains older RXPA Informational letters and PDLs.