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Louisiana Healthcare Connections Policies and Procedures Updates

Date: 05/20/25

Louisiana Healthcare Connections is sharing with providers the below policies and procedures that were developed and/or revised; posted for public comment and approved by LDH in accordance with La. R.S. 46:460.54. Non-material revisions do not require LDH approvals.

Please share this notice with other members of your practice and office staff as necessary.

These guidelines will be implemented 30 days from the date of this notice and will be posted on our Clinical & Payment Policies page.

Policy & Procedure #Policy & Procedure TitleNew, material revisions, non-manterial revisions
LA.PHAR.119Ramucirumab (Cyramza)Material
LA.PHAR.160Alglucosidase Alfa (Lumizyme)Material
LA.PHAR.187Verteporfin (Visudyne)Material
LA.PHAR.192Epoprostenol (Flolan, Veletri)Material
LA.PHAR.203Cosyntropin (Cortrosyn)Material
LA.PHAR.204Trabectedin (Yondelis)Material
LA.PHAR.260Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela)Material
LA.PHAR.28Immunization CoverageMaterial
LA.PHAR.308Elotuzumab (Empliciti)Material
LA.PHAR.312Blinatumomab (Blincyto)Material
LA.PHAR.323Plerixafor (Mozobil)Material
LA.PHAR.333Avelumab (Bavencio)Material
LA.PHAR.361Tisagenlecleucel (Kymriah)Material
LA.PHAR.362Axicabtagene ciloleucel (Yescarta)Material
LA.PHAR.367Letermovir (Prevymis)Material
LA.PHAR.371Triamcinolone ER Injection (Zilretta)Material
LA.PHAR.40Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa)Material
LA.PHAR.405Inotersen (Tegsedi)Material
LA.PHAR.410Bortezomib (Velcade)Material
LA.PHAR.415Ravulizumab-cwvz (Ultomiris)Material
LA.PHAR.444Afamelanotide (Scenesse)Material
LA.PHAR.445Brolucizumab-dbll (Beovu)Material
LA.PHAR.475Sacituzumab Govitecan-hziy (Trodelvy)Material
LA.PHAR.521Avalglucosidase Alfa-ngpt (Nexviazyme)Material
LA.PHAR.522Margetuximab-cmkb (Margenza)Material
LA.PHAR.542Talimogene laherepvec (Imlygic)Material
LA.PHAR.567Cipaglucosidase alfa-atga--miglustat (Pombiliti- Opfolda)Material
LA.PHAR.570Ropeginterferon Alfa-2b-njft (BESREMi)Material
LA.PHAR.581Faricimab-svoa (Vabysmo)Material
LA.PHAR.685Tarlatamab-dlle (Imdelltra)Material
LA.PHAR.687Tislelizumab-jsgr (Tevimbra)Material
LA.PHAR.690Imetelstat (Rytelo)Material
LA.PHAR.595Eladocagene Exuparvovec-tneq (Kebilidi)New
LA.PHAR.675Obecabtagene autoleucel (Aucatzyl)New
LA.PHAR.678Afamitresgene autoleucel (Tecelra)New
LA.PHAR.711Cosibelimab-Ipdl (Unloxcyt)New
LA.PHAR.713Zenocutuzumab-zbco (Bizengri)New
LA.PHAR.158Agalsidase Beta (Fabrazyme)Non-Material
LA.PHAR.181Hemin (Panhematin)Non-Material
LA.PHAR.189Ibandronate Injection (Boniva)Non-Material
LA.PHAR.199Treprostinil (Remodulin)Non-Material
LA.PHAR.282Parathyroid Hormone (Natpara)Non-Material
LA.PHAR.300Bezlotoxumab (Zinplava)Non-Material
LA.PHAR.301Erwinia Asparaginase (Erwinaze, Rylaze)Non-Material
LA.PHAR.330Protein C Concentrate, Human (Ceprotin)Non-Material
LA.PHAR.372Voretigene Neparvovec-rzyl (Luxturna)Non-Material
LA.PHAR.402Emapalumab-lzsg (Gamifant)Non-Material
LA.PHAR.455Enfortumab Vedotin-ejfv (Padcev)Non-Material
LA.PHAR.459Iobenguane I-131 (Azedra)Non-Material
LA.PHAR.465Teprotumumab (Tepezza)Non-Material
LA.PHAR.501Pertuzumab/Trastuzumab/Hyaluronidase-zzxf (Phesgo)Non-Material
LA.PHAR.52Interferon Gamma-1b (Actimmune)Non-Material
LA.PHAR.523Naxitamab-gqgk (Danyelza)Non-Material
LA.PHAR.563Allogenic Processed Thymus Tissue-agdc (Rethymic)Non-Material
LA.PHAR.574Sirolimus Protein-Bound Particles (Fyarro)Non-Material
LA.PHAR.610Sodium thiosulfate (Pedmark)Non-Material
LA.PHAR.616Zilucoplan (Zilbrysq)Non-Material
LA.PHAR.618Mosunetuzumab-axgb (Lunsumio)Non-Material
LA.PHAR.94Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)Non-Material
LA.PHAR.95Thyrotropin Alfa (Thyrogen)Non-Material
LA.CP.MP.101Donor Lymphocyte InfusionNon-Material
LA.CP.MP.102Pancreas TransplantationMaterial
LA.CP.MP.132Heart-Lung TransplantMaterial
LA.CP.MP.141Nonmyeloablative Allogeneic Stem Cell TransplantsMaterial
LA.CP.MP.150Phototherapy for Neonatal HyperbilirubinemiaNon-Material
LA.CP.MP.160Implantable Wireless Pulmonary Artery Pressure MonitoringNon-Material
LA.CP.MP.162Tandem TransplantMaterial
LA.CP.MP.163Total Parenteral Nutrition and Intradialytic Parenteral NutritionMaterial
LA.CP.MP.170Nerve Blocks and Neurolysis for Pain ManagementNon-Material
LA.CP.MP.246Pediatric Kidney TransplantNon-Material
LA.CP.MP.36Experimental TechnologiesNon-Material
LA.CP.MP.37cBariatric SurgeryNon-Material
LA.CP.MP.40Gastric Electical StimulationMaterial
LA.CP.MP.57Lung TransplantationMaterial
LA.CP.MP.69Intensity-Modulated RadiotherapyMaterial