Effective January 1st 2019, please submit requests for controlled substances using the new Uniform Prescription Drug Prior Authorization Form.  Please review the pharmacy authorization guidelines to ensure you have submitted all guideline requirements.

Louisiana Uniform Prescription Drug Prior Authorization Form 


The Louisiana Department of Health Resources

The Department would like to share our new “Opioid” web page. There are many great resources posted here:

April 2017 Provider Update includes Morphine Equivalent Dose information:

Formulary drug list

The formulary is a list of drugs chosen by Louisiana Department of Health's Pharmacy P & T Committee and administered by Aetna Better Health of Louisiana.  Drugs are listed as preferred and non-preferred.  All non-preferred drugs are required to follow the prior authorization process.

There is a subset of drugs not listed on the Louisiana Medicaid Single PDL which may be available for coverage.  These drugs typically do not require a prior authorization.  Generic substitution is mandated by the state unless a drug is on the preferred drug list as a Brand Name product.  Clinical edits, such as quantity limits and age restrictions, may apply to some drug categories.

Members must fill their prescriptions at an Aetna Better Health of Louisiana network pharmacy and follow other plan rules.

Please review the formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Louisiana patient.

Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations)

Aetna Better Health also covers certain over-the-counter drugs (OTC). Some drugs are covered on the state’s Single Preferred Drug List (SPDL). SPDL OTC drugs require a prescription from a provider. The links have been provided below for your review.

Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations)

Enrollees have an additional OTC benefit. Enrollees can access a catalog of available OTC drugs. You can check with Enrollee Services at 1-855-242-0802, TTY 711, for more information, how to access the catalog and assistance with orders*.

Effective May 1st, 2019, Aetna Better Health® of Louisiana adheres to the Healthy LA PDL clinical criteria to make decisions when you send in a request for a drug on the formulary/PDL that needs a review prior to being dispensed. 

To access clinical criteria, click here to be taken to the Healthy LA Pharmacy clinical criteria.


Additional criteria found below will also apply as of May 1st, 2019.

Compounds  (effective 12.02.2019)

Diabetic Testing Supplies  (effective 01.01.2021)

Quantity Level Limits  (effective 08.18.2020)



Algorithms December 2019

Hep C LA Elimination Plan

Hep C Policy Criteria (Authorized Generic(AG) Epclusa Preferred)

To quickly find a prior authorization form, click CTRL F on your keyboard and type in the form name.  

Louisiana Uniform Prescription Drug Prior Authorization Form  


Hepatitis C DAA Request Form

Hepatitis C DAA Worksheet

Hepatitis C Patient Treatment Agreement

Spinraza  (Medical Benefit only through ABHLA)









We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591


Group: RX8834

The Prescription Monitoring Program (PMP)  is accessed by utilizing the Louisiana Board of Pharmacy.

Certain drugs on the formulary have quantity limits (QLLs). The QLLs are established based on FDA-approved dosing levels and nationally- established, recognized guidelines pertaining to the treatment and management of the condition being treated.

To request an override for the quantity limit, please fax the correct pharmacy Prior Authorization request form to 1-844-699-2889. You can include any medical records that will support your request.

Pharmacy & Therapeutics Committee Meetings

10000 Perkins Rowe, Suite 500, Baton Rouge, LA. 70810, 5:30 – 7PM.  ABHLA complies with Open Meetings Laws.

Dates 2021 P&T Committee Meeting (Tentative)

  • 2021 1st Biannual Meeting, Tuesday, June 22, 2021
  • 2021 2nd Biannual Meeting, Tuesday, December 14, 2021

Dates:  2020 P&T Committee Meeting (Tentative)     

      • 1st Biannual Meeting, Tuesday, June 23, 2020 
      • 2nd Biannual Meeting, Tuesday, December 8, 2020 (cancelled) new date January 26, 2021 (virtual).

Due to limited seating, please RSVP Vanessa Smith at


*Go to the central elevator and come to the 5th floor. If the door is not open, please call (225) 315-9561 to gain access.*

Meeting agendas

January 26, 2021

June 23, 2020

December 12, 2018

February 11, 2019

December 10, 2019


If you have any questions contact:

Vanessa N. Smith, DPh

Director of Pharmacy

(504) 667-4544 Office



Pharmacy & Therapeutics Committee Guidelines

PT Committee Meeting Speakers Request Form

Special member support programs

2021 DUR Education Articles

Q1 Clinical Inertia in Type 2 Diabetes