La. Admin. Code tit. 50 § XXIX-107

Current through Register Vol. 50, No. 11, November 20, 2024

Section XXIX-107 - Prior Authorization

A. The medication must be prescribed by a practitioner who is authorized to prescribe under state law. The national drug code (NDC) must be identified on each pharmacy claim for reimbursement. Prescription drugs considered for payment are subject to rebates from manufacturers as mandated by federal law and regulations.

B. Covered Drugs. Coverage of drugs shall be limited to specific drug products authorized for reimbursement by therapeutic category and listed by generic name, strength/unit, NDC, and brand name. Those drug products subject to mandatory coverage as a result of a rebate agreement with the federal government will be covered until written notice is received from the Centers for Medicare and Medicaid Services that coverage will be terminated. Providers will be given notice of termination of coverage.

C. Prior Authorization with a Preferred Drug List

1. A prior authorization process is established which utilizes a preferred drug list (PDL) for selected therapeutic classes. Drugs in selected therapeutic classes that are not included on the PDL shall require prescribers to obtain prior authorization. Lists of covered drug products, including those that require prior authorization, will be maintained on the Louisiana Medicaid web site.

2. The prior authorization process provides for a turnaround response by either telephone or other telecommunications device within 24 hours of receipt of a prior authorization request. In emergency situations, providers may dispense at least a 72-hour supply of medication.

3. The Pharmaceutical and Therapeutics Committee will make recommendations to the Department regarding drugs to be considered for prior authorization. The composition of and appointment to the Pharmaceutical and Therapeutics Committee complies with R.S. 46:153.3(D) and 42 U.S.C.s1396r-8.

D.Drugs Excluded from Coverage. As provided by §1927(d)(2) of the Social Security Act, the following drugs are excluded from program coverage:

1. select agents when used for anorexia, weight loss, or weight gain, except Orlistat (Xenical);

2. select agents when used to promote fertility, except vaginal progesterone when used for high-risk pregnancy to prevent premature births;

3. select agents when used for symptomatic relief of cough and cold, except prescription antihistamine and antihistamine/decongestant combination products;

1. select covered outpatient drugs when used for anorexia, weight loss, or weight gain as determined by the department;

2. select covered outpatient drugs when used to promote fertility as determined by the department;

3. select covered outpatient drugs when used for symptomatic relief of cough and cold as determined by the department;

4. select prescription vitamin and mineral covered outpatient drugs as determined by the department; and

a. - o. Repealed.

5. select over-the-counter covered outpatient drugs as determined by the department.

E. Otherwise Restricted Drugs

1. The state will cover agents when used for cosmetic purposes or hair growth only when the state has determined that use to be medically necessary.

2. Select drugs for erectile dysfunction, except when used for the treatment of conditions, or indications approved by the FDA, other than erectile dysfunction.

La. Admin. Code tit. 50, § XXIX-107

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 32:1054 (June 2006), Amended by the Department of Health, Bureau of Health Services Financing, LR 431180 (6/1/2017), LR 43:1553 (August 2017), LR 45:665 (May 2019), Amended by the Department of Health, Bureau of Health Services Financing, LR 4633 (1/1/2020), Amended LR 48283, Amended LR 481582 (6/1/2022), Amended LR 492106 (12/1/2023), Amended LR 50978 (7/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, Title XIX of the Social Security Act, and the 1995-96 General Appropriate Act.