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.
Prime Therapeutics State Government Solutions (Prime Therapeutics) manages pharmacy benefits for all Healthy Louisiana Medicaid health plans, including Louisiana Healthcare Connections. For any pharmacy-related issues or questions, call Prime Therapeutics at 1-800-424-1664 (TTY: 711).
The Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF) is a list of drugs Louisiana Medicaid members can use if prescribed. The PDL applies to the drugs members can receive at retail pharmacies. It is not a complete list of covered drugs, but lists the preferred medications in the most common drug categories. The PDL also links to a list of diabetic supplies that are covered with a prescription. These include certain meters, test strips, pen needles, lancets, syringes, and insulin pumps.
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 Prime Therapeutics at 1-800-424-1664 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 medicaid Single 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.
The table below lists copayments for drugs according to the actual cost of the prescription.
| ACTUAL COST OF PRESCRIPTION | MEMBER COPAYMENT |
|---|---|
| $5.00 or less | $0.00 |
| Between $5.01 and $10.00 | $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
- Tobacco cessation products
- Vaccines
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
Some diabetic supplies are covered for Louisiana Healthcare Connections members when prescribed by an in-network provider and filled by pharmacy in Prime Therapeutics' network. You can view covered supplies on the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF). They include certain:
- Diabetes glucose meters
- Diabetic test strips
- Continuous glucose meters
- Transmitters and sensors
- External insulin pumps (e.g. Cegur Simplicity, Omnipod, and V-Go)
- Control solution
- Keytone test strips
- Lancets and devices
- Pen needles
- Re-usable insulin pens
- Syringes
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 Medicaid Single 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 pharmacy in the Prime Therapeutics network. If the member decides to have a prescription filled at a network pharmacy, the member can locate a pharmacy near them by contacting Prime Therapeutics' 24/7 Member Help Desk at 1-800-424-1664 (TTY: 711) or the member can use Prime Therapeutics' online Find a Pharmacy 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 is 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 does Louisiana Healthcare Connections 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.
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 Prime Therapeutics at 1-800-424-1664.
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 Prime Therapeutics through covermymeds.com or on the Louisiana Uniform Medicaid Prescription Drug Prior Authorization Form (PDF). This form should be faxed to Prime Therapeutics at 1-800-424-7402.
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 Authorization requests are sent to Prime Therapeutics and reviewed using the criteria established by the Louisiana Department of Health’s DUR committee. PA decisions are made within 24 hours from when all clinical information is received from the prescriber.
If the request is approved, Prime Therapeutics notifies the practitioner. If the clinical information provided does not meet the coverage criteria for the requested medication, Prime Therapeutics will notify the member and their practitioner of alternatives and provide information regarding the appeal process.
Find more information in our Retail (Outpatient) Pharmacy Authorization Process Guide (PDF).
There may be limits on 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 from Prime Therapeutics. If Prime Therapeutics does not grant PA, they will notify the member and their practitioner and provide information regarding the appeal process.
Prime Therapeutics contracts with a number of specialty pharmacies to ensure members have adequate access to the specialty drugs they require. Some 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.
Some tobacco cessation medications, such as gums, lozenges and patches, are covered for members over the age of 18 with no pharmacy copayment. 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.
Contact Information
Retail Pharmacy Prior Authorization Requests
1-800-424-1664
Fax: 1-800-424-7402
Pharmacy Services Resolution Help Desk
Medical Pharmacy/Biopharmacy Prior Authorization Requests for Office-Administered Drugs
1-866-595-8133
Fax: 1-866-925-3006