La. Admin. Code tit. 50 § XXIX-115
Current through Register Vol. 50, No. 11, November 20, 2024
Section XXIX-115 - Drug Coverage LimitsA. Reimbursement for multi-source prescription drugs shall be limited in accordance with state and federal law and rules pertaining thereto, with the following exception: reimbursement shall be provided for any drug prescribed by a prescribing provider that, in his professional judgment and within the lawful scope of his practice, he considers appropriate for the diagnosis and treatment of the patient with the following limitations. 1. The prescribed drug has been approved and designated as safe and effective by the Food and Drug Administration.2. The prescribed drug is not classified as a DESI drug (drugs which have been identified by the FDA as lacking evidence of safety/effectiveness).3. The prescribed drug is not a compounded prescription (mixtures of two or more ingredients).4. The prescribed drug is not methadone prescribed only for narcotic addiction.5. The prescription is not for medications which are included in the reimbursement to Title XIX facilities, including, but not limited to: a. hospitalized recipients;b. recipients receiving benefits under Part A of Title XVIII in a skilled nursing facility; orc. resident/patients at Villa Feliciana or any state mental hospital.6. The prescribed drug is an excluded or otherwise restricted drug.7. The prescribed drug is not an experimental or investigational drug which are generally labeled: Caution-limited by federal law to investigational use, unless a specific exception has been granted by the federal government.
8. The prescribed drug is not an immunosuppresant drug prescribed and billed to Medicare for a Title XIX transplant recipient who has Medicare Part B coverage.9. The prescribed drug is not an immunosuppressant drug covered by Medicare Part B which is prescribed for a nontransplant patient with Medicare Part B coverage and identified in the Title XIX provider manual as subject to special billing procedures.B. Drug Listing 1. The bureaus fiscal intermediary or agent will provide coverage information on any specific drug. Providers should contact the fiscal intermediarys or agents provider/pharmacy relations unit when a specific coverage question arises.2. The Title XIX provider manual shall include a listing of examples of prescribed medications and/or supplies which are not payable under pharmaceutical services of the Medicaid Program.La. Admin. Code tit. 50, § XXIX-115
Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 32:1055 (June 2006), LR 32:2083 (November 2006), Amended by the Department of Health, Bureau of Health Services Financing, LR 431182 (6/1/2017), Amended by the Department of Health, Bureau of Health Services Financing, LR 4634 (1/1/2020).AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.