LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT PRIOR AUTHORIZATION PROGRAM
EFFECTIVE JUNE 10, 2002


AUTHORIZING LEGISLATION

Act 395 of the Regular Session of the 2001 Louisiana Legislature amended R.S. 46:153.3 (B) and (C) and permits the Louisiana Department of Health (LDH) to utilize a prior approval process for its Medicaid prescription drug program.

In State Fiscal Year 2001, the Louisiana Medicaid Program paid for 12,545,632 prescriptions. Between 1995 and 1999, the drug expenditures percentage rose from 10% to 12% of the total Medicaid budget. This pattern of increasing expenditures was projected to continue. Until the 2001 legislative session, Louisiana was prohibited from utilizing a prescription drug prior approval process in the Louisiana Medicaid Program. With the passage of Act 395, this restriction was removed, and LDH implemented a Preferred Drug List (PDL) with a Prior Authorization (PA) process.

Initially implemented in June 2002, LDH utilizes the services of both Gainwell Technologies and the University of Louisiana Monroe (ULM), College of Pharmacy to operate the Prior Authorization system.

DRUGS REQUIRING PRIOR AUTHORIZATION (PA)

Drugs are considered "preferred" or "non-preferred". "Non-preferred" drugs will require a PA. The current PDL is available here.

HOW TO OBTAIN PRIOR AUTHORIZATION

The prescribing practitioner may obtain prior authorization (PA) by (1) electronic Prior Authorization (E-PA), (2) telephone, (3) facsimile, or (4) mail to the University of Louisiana Monroe, College of Pharmacy. The requests are evaluated, and the pharmacist reviewer makes a decision. The decision is communicated by phone before the conclusion of a phone request. Responses to E-PA, fax or mail requests are delivered electronically, faxed or mailed to the requestor within twenty-four (24) hours of receipt of a PA request. Approved requests are added to the claims adjudication system.

Method Used to Request Prior Authorization (PA) Contact Information*
Electronic Prior Authorization (E-PA) Louisiana Medicaid (lamedicaid.com)
Phone: 1-866-730-4357
Fax: 1-866-797-2329
Mail: ULM College of Pharmacy
Rx PA Program
1800 Bienville Drive
Monroe, LA 71201-3765
* ULM Prior Authorization Unit hours of operation are 8 a.m. to 6 p.m. Central Time, Monday through Saturday.

(NOTE: The POS Help Desk has NO relationship to the PA Unit or the PA request process.)

WHO CAN OBTAIN PRIOR AUTHORIZATION:

The prescribing practitioner is responsible for obtaining prior authorization.

Prescribing practitioners include:

Physicians (MD & DO, including interns, residents and fellows)
Dentists
Podiatrists
Optometrists
Nurse Practitioners with Prescribing Authority
Nurse Midwives with Prescribing Authority
Clinical Nurse Specialists with Prescribing Authority

The prescribing practitioner must have and provide his/her valid individual LA Medicaid prescribing provider number or National Provider Identifier Number (NPI) to obtain prior authorization. (Only individual provider numbers will be accepted.)

HOW TO OBTAIN A PROVIDER NUMBER:

If a prescribing practitioner does not currently have an individual LA Medicaid provider number, it is important to request a number immediately in order to prevent prior authorization delays/denials.

Contact Gainwell Technologies Provider Enrollment @ 225-923-8510 or 1-833-641-2140 to obtain a LA Medicaid provider number.

PA APPROVAL PROCESS: APPROVED REQUESTS, DENIED REQUESTS, AND VOIDS:

  • When a PA request is received, the ULM PA Unit has 24-hours from the date and time received to (1) approve, (2) deny, or (3) void the request. NO retroactive PA approvals will be given.
  • A PA will be approved for a specific period of time with a maximum approval period of one (1) year. The only exception to the maximum approval period applies to antipsychotics under certain clinical circumstances; these medications may receive longer approvals based on Act 76 of the Regular Session of the 2022 Louisiana Legislature. Approvals are not given based on prescriptions or number of refills. (Example: PA may be given for a particular drug for a one-year period during which multiple prescriptions with multiple refills may be written; subsequent prescriptions for the same authorized drug do not need to be prior authorized as long as the prescription and refills fall within the one-year PA approval period.)
  • The PA prescription time limit and number of refills edit will supersede the prescription time and refill program limits.
    • Example (1): A drug is prior authorized for a period of one (1) month. The prescribing practitioner issues a prescription for 6 months (original plus five refills). The claim for the first month dispensed will process and pay based on the one-month authorization. Any refills dispensed after the PA period has ended will deny because the original authorization has expired and is no longer valid for the additional refills.
    • Example (2): A drug is prior authorized for a period of twelve (12) months. The prescriber issues a prescription for 6 months (original plus five refills). When the prescription refills have been exhausted, the prescriber must issue a new prescription for the remaining 6 months of the authorization, but does not need a new PA at that time as 6 months of authorization remain.

Approved requests:

When a request is approved, the prescribing practitioner will be notified via phone, fax, electronic means, or through written correspondence via first class mail through the U.S. Postal Service.

The authorization is then established in the PA system and the POS claims processing system, allowing claims for authorized medications to process without further intervention by the pharmacist. However, all existing POS claim edits will continue to be applied.

Denied requests:

When a request is denied, the prescribing practitioner will be notified via phone, fax, electronic means, or through written correspondence via first class mail through the U.S. Postal Service. The recipient will also be notified and advised of the appeal process by written correspondence via first class mail through the U.S. Postal Service.

Voids:

When a request is voided, the prescribing practitioner will be notified via phone, fax, electronic means, or through written correspondence via first class mail through the U.S. Postal Service. Some of the reasons for which requests are voided include, but are not limited to, the following:

  • Incomplete fax or mail request form;
  • Fax or mail request not submitted on the accepted form;
  • Phone call is terminated prematurely by requestor;
  • Phone call is terminated prematurely for unknown/other reason;
  • PA request received from a non-prescribing practitioner;
  • Invalid or missing recipient number;
  • Invalid or missing recipient date of birth;
  • Recipient name and number do not match;
  • PA not required for this drug.
  • Duplicate request.

MEDICAL REVIEW PROCESS

In cases where a PA request is denied, the prescribing provider may request a phone consultation with a ULM Prior Authorization Unit physician.

A final determination (approval or denial) through the ULM PA Unit will be made by the physician consultant within 48 hours following this phone conference. This decision will be based on the clinical aspects of the case.

APPEAL PROCESS

LDH will administer the appeals process.

THE PRIOR AUTHORIZATION FORM

The PA form is available on the LA Medicaid Preferred Drug List (PDL).

FOR PHONE REQUESTS:

  • The PA Operator will ask questions based on the criteria associated with the requested drug.
  • Information provided must be complete. Incomplete requests will not be processed and will be voided.
  • Phone requests will receive phone responses.

FOR FAXED OR MAILED REQUESTS:

  • ONLY the completed, legible, designated form will be accepted.
  • All fields on the form should be completed.
  • The individual LA Medicaid provider number or NPI of the prescribing practitioner is required.
  • Incomplete forms will be voided.
  • A faxed or mailed request will receive a faxed or phone response. Responses will be mailed only if a fax or phone number is not available.

FOR E-PA REQUESTS:

  • All required information should be provided in the appropriate fields.
  • E-PA requests will receive responses via the electronic portal.

EMERGENCY PROCEDURES

Prescriptions indicating emergency situations shall be dispensed in a MINIMUM quantity of a 3-day supply. Refills for the dispensing of the non-preferred products in these emergency situations are not permitted. The recipient’s practitioner must contact the PA Unit to request authorization to continue the medication past the emergency supply, and a new prescription must be issued.

This process may be used when the PA Unit is closed (Sundays; Monday-Saturday before 8 a.m. and after 6 p.m.; Selected Holidays) or when the PA system is unavailable. The pharmacist may also use professional judgment in situations that would necessitate an emergency supply.

If the prescription is a hard copy prescription, the prescribing practitioner must indicate that this is an emergency prescription on the face of the prescription. If the prescription is called in to the pharmacy, the emergency status of the prescription must be communicated to the pharmacist who must indicate "Emergency Rx" on the hard copy prescription or in an electronic record-keeping system. When the pharmacist determines the prescription is an emergency, the pharmacist must indicate "Emergency by Pharmacist" on the hard copy prescription or in an electronic record-keeping system. The pharmacist must code the claim as an emergency prescription (enter "03" in NCPDP Field #487).

Recipients are exempt from paying co-payments for prescriptions dispensed in emergency situations.

LDH will monitor emergency prescriptions on an ongoing basis through management reports, pharmacy provider audits, and other review programs to review the number of these prescriptions and the reasons for the emergencies.

IMPORTANT FACTS

  • If an approved PA exists in the system, the pharmacy claim will pass the PA edit and continue with existing POS edits. If an approved PA does not exist, the pharmacy claim will be denied through the POS system.
  • An approved PA does not guarantee payment of the claim by Medicaid. All existing POS claim edits will continue to be applied.
  • The PA process does not verify recipient Medicaid eligibility. It only verifies that the recipient is "on file" (i.e., has a valid Medicaid ID number on file – not that the recipient is eligible on the date of service).
  • Recipient eligibility will continue to be verified by the Pharmacy POS subsystem or through the MEVS or REVS automated recipient eligibility systems.

Pharmacy Prior Authorization Program Contact Information

Additional Helpful Numbers