Frequently Asked Questions
1. What is the Pharmacy Carve-In?
The term Pharmacy Carve-In refers to the pharmacy benefit being added to the list of healthcare services that are administered by Louisiana Healthcare Connections. The Louisiana Healthcare Connections members will transition from the state managed pharmacy program to Louisiana Healthcare Connections as of November 1, 2012.
2. What is the Transition of Care Policy?
A new member to the plan or an existing member using a maintenance medication that is not on the PDL will, in general, be able to continue to get their medication for sixty (60) days. If the medication is a mental health drug, the member, in general, will be able to continue to get their medications for ninety (90) days.
Mental health drugs include the following therapeutic classes: Antianxiety Agents, Antidepressants, Antipsychotics, Antimanic Agents, Attention Deficit Hyperactivity Disorder (ADHD) Agents, Psychotherapeutic Agents, and Anticonvulsants.
If the drug is non-preferred on the PDL then the prescriber or physician must reach out and either call/fax in for prior authorization approval for the medication. We will grant continuity of care if in fact the member is on the medication. Patients that have not been on the medication previously will be put through the standard criteria for non-preferred drug approval.
Prior Authorization #1-888-929-3790
Prior Authorization Fax #1-866-399-0929
After this continuity of care period, the physician must do one of the following:
A. Submit an authorization request on the Medication Prior Authorization Request Form; or
B. Transition the member to a drug that is listed on the PDL.
NOTE: Members that are taking maintenance mental health medications that are not listed on the PDL may continue to get the medication for an additional 275 days if the drug is being used within the drug’s restriction guidelines (i.e. quantity limits, age limits, etc.).
For members currently enrolled in the plan that are being discharged from state mental health hospitals, the transition policy will apply but is not automatically applied in the system. The pharmacy or the physician should contact US Script to inform them of the member’s hospital discharge.
3. Are OTC drugs covered?
The pharmacy program covers a selection of over-the-counter medications. The over-the-counter medications that are covered are listed in the Preferred Drug List. All over-the-counter medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed.
4. What about drugs that are NOT listed on the PDL?
If a drug is not listed on the Preferred Drug List a Medical Necessity (MN) request will need to be submitted and approved for the medication to be covered by Louisiana Healthcare Connections. The MN request should be submitted by the member’s physician/clinician on the Medication Prior Authorization Request Form. Instructions on where it should be faxed are on the top of the form.
5. What happens if a drug on the Preferred Drug List has a restriction or limitation on it?
If the drug is listed on the Preferred Drug List but has a PA, ST, QL, or AL restriction on it AND the request is outside of the parameters, an authorization request must be submitted. The request should be submitted by the member’s physician/clinician on the Medication Prior Authorization Request Form. Instructions on where it should be faxed are on the top of the form.
6. Are specialty medications, such as biopharmaceuticals and injectables, covered?
Louisiana Healthcare Connections covers certain specialty medications. All specialty medications require authorization to be approved for payment by Louisiana Healthcare Connections. Some specialty medications can be administered from the provider’s office stock while other medications will need to be filled by a specialty pharmacy.
The request should be submitted by the member’s physician/clinician on the Medication Prior Authorization Request Form. Instructions on where it should be faxed are on the top of the form.
7. Can a PA be requested verbally?
Clinical documentation must be provided in order for the request to be reviewed. Verbal requests cannot be accepted by the Pharmacy Department.
8. Who is US Script?
Louisiana Healthcare Connections works with US Script to process all pharmacy claims for prescribed drugs. Some drugs on the Louisiana Healthcare Connections PDL require a PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager (PBM).
Pharmacy Call Center: 1-877-690-9330
Mailing Address: 2425 W Shaw Ave, Fresno, CA 93711
PA Phone: 1-888-929-3790
PA Fax: 1-866-299-0929
Clinical Hours: Monday – Friday 9AM to 7PM CST
9. What is the P&T Committee and who can attend the meetings?
The Louisiana Healthcare Connections Pharmacy and Therapeutics (P&T) Committee is a group of Louisiana physicians, pharmacists, dentists, and specialists that are responsible for evaluating the Preferred Drug List to ensure it promotes the appropriate and cost-effective use of medications.
The Louisiana Healthcare Connections Medical Director and Director of Pharmacy lead the meeting and present the materials for the Committee’s review. Meetings are open to the public. The dates of the meeting will be posted to the plan website to provide adequate notification to those individuals that are interested in attending.
10. Is there a transition period for drug coverage?
In general Louisiana Healthcare Connections allows members to continue treatment with medications for 60 days after a member joins the plan. If the treatment is an antidepressant or antipsychotic, the medication will be covered for 90 days after the member enrolls in the plan.
If the member is taking a non-PDL drug, the member and clinician should use the 60 or 90 day period to transition to a medication on the Preferred Drug List OR submit an authorization request to continue treatment with the current medication therapy. The member’s physician will be notified by letter prior to the end of the transition period if a drug the member has been taking will require authorization following the transition period.
11. How does a member get his or her medications?
Members can have prescriptions filled at a network pharmacy. At the pharmacy, he or she will need to provide the pharmacist with the prescription and the Louisiana Healthcare Connections ID card. If a member requires assistance finding a pharmacy they should call Louisiana Healthcare Connections Member Services or use the Provider Directory.
The Provider Directory can be found by using the Find a Provider tool on the Louisiana Healthcare Connections website. After selecting Find a Provider, click on Provider Directory. Type in the city or zip code, then click on Update. Choose Other and type the name of the pharmacy or select the pharmacy type in the Select Specialty area. Only the network pharmacies are listed.
12. Will a member have a copayment when filling his or her prescription?
Louisiana Healthcare Connections members will have a copayment based on the total cost of the prescription. The copayments located in the table below. There are no copayments for members under the age of 21, women that are pregnant, family planning supplies, members living in a nursing home, members in the hospital, Alaskan Eskimo members, or American Indian members. If a member can not pay their copayment they can get their medication but will still owe the copayment to the pharmacy.
|Actual Costs of Prescription||Member Copayment Amount|
|Less than $10.00||$0.50|
|Between $10.01 and $25.00||$1.00|
|Between $25.01 and $50.00||$2.00|
|More than $50.01||$3.00|
13. Are there dispensing limits?
Drugs may be dispensed up to a maximum 30 day supply for each new prescription or refill. A total of 85% of the days’ supply must have elapsed before the prescription can be refilled.
14. Are generic drugs mandatory when available?
When generic drugs are available, the brand name drug will not be covered without Louisiana Healthcare Connections authorization. Generic drugs have the same active ingredient, work the same as brand name drugs, and have lower copayments. If a member or their physician feels a brand name drug is medically necessary, the physician can submit an authorization request on the Medication Prior Authorization Request Form.
There are a few drugs that do not apply to the mandatory generic rule due to their narrow therapeutic index (NTI). These drugs include the following: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin.
15. What if a member needs to fill a prescription but doesn’t have an ID card?
The pharmacy should call Louisiana Healthcare Connections Member Services to verify plan eligibility. If the member is eligible Member Services can provide the pharmacy with the member number and the US Script BIN.
16. Are retroactive authorization requests allowed?
All medications must be approved prior to dispensing or administering. Retroactive authorizations cannot be reviewed or entered by the Pharmacy Department.