Preferred Drug List

Envolve Pharmacy Solutions is Louisiana Healthcare Connections' Pharmacy Benefit Manager. We work with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Some drugs on the Louisiana Healthcare Connections PDL require Prior Authorization (PA), and US Script is responsible for administering this process.

Louisiana Healthcare Connections contracts with a number of specialty pharmacies to ensure members have adequate access to the specialty drugs they require. All 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.

For providers wishing to have a specialty drug distributed by a specialty pharmacy that is contracted with Louisiana Healthcare Connections, the listing of specialty medications requiring PA can be found in the Specialty Drug Benefit document.

For a listing of office administered specialty medications that require PA, please refer to the Office Administered Drug Prior Authorization List.

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.

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.

Additional information about the drugs that are part of the these edits can be found in the Appropriate Use and Safety Edits document.

Some medications listed on the Louisiana Healthcare Connections PDL may require PA. The information should be submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization Form. This form should be faxed to US Script at 1-866-399-0929. This document is located on the Louisiana Healthcare Connections website at www.louisianahealthconnect.com.

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.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Louisiana Healthcare Connections P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Louisiana Healthcare Connections will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Some medications listed on the Louisiana Healthcare Connections PDL 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 their practitioner 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 his or her practitioner and provide information regarding the appeal process.

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.

Some medications on the Louisiana Healthcare Connections' PDL may be limited to one gender. These limits are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals.

If the member requires a medication that does not appear on the PDL, 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 at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or
• Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); 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 Healthcare Connections 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 his or her practitioner of alternatives and provide information regarding the appeal process.

State and Federal laws require that a pharmacy dispense a 72-hour (3 day) supply of medication to any member awaiting PA determination. 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 and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call US Script at 1-888-929-3790 for a prescription override to submit the 72-hour medication supply for payment.

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
• 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
• Compounded prescriptions (mixtures of two or more ingredients; the individual drugs will continue to be reimbursed)

Louisiana Healthcare Connections reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If Louisiana Healthcare Connections does not grant PA, we will notify the member and his or her practitioner and provide information regarding the appeal process.

The Louisiana Healthcare Connections PDL covers a variety of OTC medications. A list of covered OTC medications can be found in the Over-the-Counter Medications section Comprehensive Preferred Drug List. These OTCs are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

The following types of tobacco cessation medications will be covered by Louisiana Healthcare Connections for members over the age of 18 and participating in an approved smoking cessation program: generic nicotine replacement products (gum, lozenges, and patches) and bupropion SR (Zyban). A prescription will be required for all tobacco cessation medications.

Louisiana Healthcare Connections authorizes benefits for tobacco cessation medications for the purpose of supporting members who are trying to quit tobacco use with the temporary assistance of nicotine replacement therapy. It is expected that utilization of these products will be in accordance with medical standards of practice, FDA guidelines and manufacturers’ recommendations which generally limit product use to approximately 12 weeks.

When generic drugs are available, the brand-name drug will not be covered without PA. Generic drugs have the same active ingredient, work the same as brand-name drugs and have lower co-payments. If the member or practitioner feels a brand-name drug is medically necessary, the practitioner can request the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason for the member needing the particular brand-name drug. If Louisiana Healthcare Connections does not grant PA, we will notify the member and his or herpractitioner and provide information regarding the appeal process.

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.

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 Louisiana Healthcare Connections.

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 the pharmacy, the member will need to provide the pharmacist with the prescription and a Louisiana Healthcare Connections ID card.

The table below lists the copayment for the drugs according to the actual cost of the prescription. Copayments are not required for children under the age of 21, pregnant women, family planning supplies, members in the hospital or a nursing home, Alaskan Eskimo members, or American Indian members.

Fax the following PA requests to the corresponding fax number: