Preferred Drug List
Louisiana Healthcare Connections is committed to providing appropriate, high quality and cost effective drug therapy to all our members. Louisiana Healthcare Connections works with providers and pharmacists to ensure medications used to treat a variety of conditions and diseases are covered. Louisiana Healthcare Connections covers prescription medications and certain over-the-counter (OTC) medications when ordered by a Louisiana Medicaid enrolled, Louisiana Healthcare Connections practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage and maximum quantities.
The Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF) is the list of covered drugs. The PDL applies to the drugs members can receive at retail pharmacies.
State and Federal laws require that a pharmacy dispense a 72-hour (3 day) supply of medication to any member when a PA has not been resolved. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72-hour supply of medication or unbreakable package size and will be reimbursed for the ingredient cost and dispensing fee of the medication. The pharmacy may call Envolve Pharmacy Solutions at 1-888-929-3790 for a prescription override to submit the 72-hour medication supply for payment or the pharmacy can submit the 72-hour override code in the claim.
Some medications on the Louisiana Healthcare Connections' PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.
The health and safety of the member is a priority for Louisiana Healthcare Connections. One of the ways we address member safety is through point-of sale (POS) edits when a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.
Note: Now that the COVID-19 public health emergency has ended, copayment on prescriptions have recommenced.
|ACTUAL COST OF PRESCRIPTION
|$10.00 or less||$0.50|
|Between $10.01 and $25.00||$1.00|
|Between $25.01 and $50.00||$2.00|
|$50.01 or more||$3.00|
The total amount members pay for medicine can’t be more than 5% of their family’s income each month. Once the member reaches this limit, they won’t have any more copays for the rest of the month.
Exempt from Copay:
- The following pharmacy services are exempt from the copayment requirements:
- Services furnished to pregnant members
- Emergency services
- Family planning services
Preventive medications as designated by the US Preventive Services Task Force A and B Recommendations
The following populations are exempt from copayment requirements:
- Individuals under 21 years of age
- Individuals living in a long term care facility
- Individuals receiving hospice care
- Native Americans
- Alaska Natives
- Home and Community Based Waiver recipients
- Members whose basis of Medicaid eligibility is breast or cervical cancer
Drugs may be dispensed up to a maximum of thirty (30) days supply for each new prescription or refill. A total of 85% of the days supply must have elapsed before the prescription can be refilled for all drugs except controlled medications. For controlled medications, a total of 90% of the days supply must have elapsed before the prescription can be refilled.
DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by the Louisiana Department of Health or Louisiana Healthcare Connections.
The following drug categories are not part of the Louisiana Healthcare Connections PDL and are not covered by the 72 hour emergency supply policy:
- Drugs that are considered experimental, except experimental drugs used during a public health emergency
- Drug Efficacy Study and Implementation (DESI) drugs
- Drugs prescribed for weight loss (with the exception of orlistat)
- Drugs prescribed for infertility
- Drugs prescribed for erectile dysfunction
- Drugs prescribed for cosmetic purposes or hair growth
- Cough and cold preparations
A member can have prescriptions filled at a Louisiana Healthcare Connections network pharmacy. If the member decides to have a prescription filled at a network pharmacy, the member can locate a pharmacy near them by contacting Louisiana Healthcare Connections Member Services at 1-866-595-8133, Monday – Friday, 7 a.m. to 7 p.m. Or the member can use our online Find a Provider tool.
At the pharmacy, the member will need to provide the pharmacist with the prescription and a Louisiana Healthcare Connections ID card.
Generic drugs have the same active ingredient, work the same as brand-name drugs and have lower co-payments. Covered generic drugs are listed in the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF).
There shall be a mandatory generic substitution for all drugs, when a generic is available, unless the brand is justified with applicable DAW codes or the brand is preferred.
Except for the use of approved generic drug substitution of brand drugs, under no circumstances shall the MCO permit the therapeutic substitution of a prescribed drug without a prescriber’s authorization.
The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid and Warfarin.
If the member requires a medication that is nonpreferred, the member’s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare, and PDL medications will be appropriate to treat the vast majority of medical conditions. Louisiana Healthcare Connections requires the following:
- Documentation of failure of one PDL agent within the same therapeutic class for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or
- Documented intolerance or contraindication to one PDL agent within the same therapeutic class; or
- Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.
All reviews are performed by a licensed clinical pharmacist using the criteria established by the Louisiana Department of Health’s P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication, Louisiana Healthcare Connections will notify the member and Envolve Pharmacy Solutions will notify their practitioner of alternatives and provide information regarding the appeal process.
Any new drug introduced into the market, where the labeler participates in the drug rebate program, may be considered non-preferred and may require prior-authorization until the new drug is reviewed by the State P&T Committee. The State Drug Utilization Review (DUR) Board may review and recommend clinical criteria for the new drug.
Some OTC medications are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. To determine if an OTC drug is covered, call Louisiana Healthcare Connections at 1-866-595-8133.
Some medications listed on the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) may require PA. The information should be submitted by the practitioner or pharmacist to Envolve Pharmacy Solutions on the Louisiana Uniform Medicaid Prescription Drug Prior Authorization Form (PDF). This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929.
Louisiana Healthcare Connections will cover the medication if:
- There is a medical reason the member needs the specific medication.
- Depending on the medication, other medications on the PDL have not worked.
Prior Authorizations request are sent to Envolve Pharmacy Solutions and initially reviewed by a pharmacy technician using the criteria established by the Louisiana Department of Health’s DUR committee. If these request cannot be approved, the request is forwarded to a pharmacist for further review. If the request is approved, Envolve Pharmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Envolve Pharmacy Solutions will notify the member and their practitioner of alternatives and provide information regarding the appeal process.
Louisiana Healthcare Connections may limit how much medication a member can get at one time. If the practitioner has a medical reason for increasing the amount of medication a member receives, a PA may be requested. If Louisiana Healthcare Connections does not grant PA, we will notify the member and Envolve Pharmacy Solutions will notify their practitioner and provide information regarding the appeal process.
Louisiana Healthcare Connections contracts with a number of specialty pharmacies to ensure members have adequate access to the specialty drugs they require. Most specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by Louisiana Healthcare Connections. PA requirements are programmed specific to the drug.
Some medications listed on the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) may require specific medications to be used before the member can receive the step therapy medication. If Louisiana Healthcare Connections has a record that the required medication was tried first, the step therapy medications are automatically covered. If Louisiana Healthcare Connections does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If Louisiana Healthcare Connections does not grant PA, we will notify the member and Envolve Pharmacy Solutions will notify their practitioner and provide information regarding the appeal process.
Some tobacco cessation medications, such as gums, lozenges and patches, are covered for members over the age of 18. Covered products are listed in the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF). A prescription will be required for all tobacco cessation medications. Some products require PA and/or participation in an approved tobacco cessation program.