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Louisiana Uniform Rx Prior Authorization Form 450

Louisiana Medicaid fee-for-service and every Healthy Louisiana managed care plan accept one prescription drug prior authorization form, the Louisiana Uniform Prescription Drug Prior Authorization Form (form 450). Prescribers meet it whenever a drug on the state's single preferred drug list needs prior authorization, including physician-administered drugs and opioids. The Louisiana Department of Health copy starts with a cover sheet for routing the request to the member's plan.

Who completes it

The prescriber completes Sections II to VIII: prescriber and patient details, the drug, ICD-10 diagnoses and labs, opioid attestations when relevant, prior treatments and the justification, then signs. Section I records where and when the request was submitted.

Submitting and payment

How to submit it
Check the member's plan on the LDH cover sheet and fax the form to that plan's retail pharmacy or physician-administered drug line: fee-for-service Legacy Medicaid, Aetna Better Health, AmeriHealth Caritas, Healthy Blue, Humana, Louisiana Healthcare Connections or UnitedHealthcare.

Good to know

  • Section III flags patients being discharged from a hospital, psychiatric facility or residential substance use facility, long-term care residents, and any EPSDT support coordinator.
  • Opioid requests complete Section VI: whether quantity or cumulative daily MME exceeds limits, plus attestations on pain assessment, substance use screening, PMP checks and an opioid treatment agreement.
  • Long-acting opioid attestations include around-the-clock need and at least two weeks of short-acting opioids for the condition, with that trial recorded in Section VII.
  • Palivizumab has its own clinical authorization and reconsideration forms. LDH also posts RXPA instructions and a retroactive eligibility process (Appendix D) on the same page.

Get the official form

Download the current version from the source each time; forms change without notice.

Louisiana Uniform Prescription Drug Prior Authorization Form

Official pagePDF

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Do Healthy Louisiana plans accept the uniform prescription PA form?

Yes. LDH describes it as the pharmacy prior authorization form for fee-for-service Medicaid and the MCO plans, effective January 1, 2019. The cover sheet lists fax lines for Aetna Better Health, AmeriHealth Caritas, Healthy Blue, Humana, Louisiana Healthcare Connections, UnitedHealthcare and fee-for-service Legacy Medicaid.

Can the Louisiana uniform form be used for physician-administered drugs?

Yes. Section IV has fields for provider-administered drugs, including the HCPCS or CPT code, NDC, dose per administration and whether the drug is given in the physician's office. Several plans list a separate fax for physician-administered or medical benefit drugs on the cover sheet.