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Louisiana Healthcare Connections Policies and Procedures Updates

Date: 03/17/25

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-material revisions
LA.PHAR.305Obinutuzumab (Gazyva)Material
LA.PHAR.311Belinostat (Beleodaq)Material
LA.PHAR.313Pralatrexate (Folotyn)Material
LA.PHAR.314Romidepsin (Istodax)Material
LA.PHAR.321Panitumumab (Vectibix)Material
LA.PHAR.324Temsirolimus (Torisel)Material
LA.PHAR.353Pegaspargase (Oncaspar), Calaspargase Pegol-mknl Material
LA.PHAR.358Gemtuzumab Ozogamicin (Mylotarg) Material
LA.PHAR.506Antithymocyte Globulin (Atgam, Thymoglobu-lin)Material
LA.PMN.255No Coverage CriteriaNon-Material
LA.PHAR.564Antithrombin III (ATryn, Thrombate III) Non-Material
LA.PHAR.651DaxibotulinumtoxinA-lanm (Daxxify)Non-Material
LA.PHAR.655Motixafortide (Aphexda)Non-Material
LA.PHAR.328Asfotase Alfa (Strensiq)Non-Material
LA.PHAR.398Moxetumomab pasudotox-tdfk (Lumoxiti)Non-Material