This website is for testing purposes only.
Please use www.LAMedicaid.com
On this page is a compilation of the obsolete pages as they correspond to the revision date. Click on a date to see the manual chapter page(s) prior to the revision.
Pages replaced from 04/22/2025 revision – Section 37.3 – Reimbursement
Pages replaced from 04/15/2025 revision – Section 37.1 – Covered Services, Exclusions, and Limitations
Pages replaced from 03/07/2025 revision – Section 37.0 – Overview
Pages replaced from 03/07/2025 revision – Section 37.2 – Provider Requirements and Participation Guidelines
Pages replaced from 03/07/2025 revision – Section 37.3 – Reimbursement
Pages replaced from 03/07/2025 revision – Section 37.5 – Appendixes
Pages replaced from 03/07/2025 revision – Section 37.5.1 – Forms and Links
Pages replaced from 03/07/2025 revision – Section 37.5.3 – Glossary and Acronyms
Pages replaced from 03/07/2025 revision – Section 37.5.4 – Contact Information
Pages replaced from 03/07/2025 revision – Section 37.5.6 – Prescribers
Pages replaced from 03/07/2025 revision – Section 37.5.7 – Medicare Prescription Drug Coverage
Pages replaced from 03/07/2025 revision – Section 37.5.8 – Claims Submission and Processing Payments
Pages replaced from 03/07/2025 revision – Section 37.5.9 – Public Health Services 340B Drug Pricing Program
Pages replaced from 03/07/2025 revision – Section 37.5.10 – Total Parenteral Nutrition (TPN)
Pages replaced from 03/07/2025 revision – Section 37.5.11 – Medication Administration
Pages replaced from 03/07/2025 revision – Section 37.5.12 – Patient Counseling and Drug Utilization Review (DUR)
Pages replaced from 03/07/2025 revision – Section 37.5.13 – Lock-In Program
Pages replaced from 03/07/2025 revision – Section 37.5.15 – Third Party Liability/Coordination of Benefits
Pages replaced from 01/24/2025 revision – Section 37.5.15 - Third Party Liability/Coordination of Benefits
Pages replaced from 12/10/2024 revision – Section 37.5.2 – Claims Related Information
Pages replaced from 10/25/2024 revision – Section 37.3 – Reimbursement
Pages replaced from 06/17/2022 revision – Section 37.5.12 – Patient Counseling and Drug Utilization Review (DUR)
Pages replaced from 05/06/2024 revision – Title Page
Pages replaced from 05/06/2024 revision – Section 37.1 – Covered Services, Exclusions, and Limitations
Pages replaced from 05/06/2024 revision – Section 37.2 – Provider Requirements and Participation Guidelines
Pages replaced from 05/06/2024 revision – Section 37.3 – Reimbursement
Pages replaced from 05/06/2024 revision – Section 37.5.6 – Prescribers
Pages replaced from 05/06/2024 revision – Section 37.5.8 – Claims Submissions and Processing Payments
Pages replaced from 05/06/2024 revision – Section 37.5.10 – Total Parenteral Nutrition
Pages replaced from 05/06/2024 revision – Section 37.5.11 – Medication Administration
Pages replaced from 05/06/2024 revision – Section 37.5.13 – Lock-In Program
Pages replaced from 10/30/2023 revision – Section 37.1 – Covered Services, Exclusions, and Limitations
Pages replaced from 06/26/2023 revision – Section 37.5.1 – Forms and Links
Pages replaced from 04/28/2023 revision – Table of Contents
Pages replaced from 04/28/2023 revision – Section 37.1 – Covered Services, Limitations, and Exclusions
Pages replaced from 01/26/2023 revision – Section 37.2 – Provider Requirements and Participation Guidelines
Pages replaced from 01/26/2023 revision – Section 37.5.15 – Third Party Liability/Coordination of Benefits
Pages replaced from 09/06/2022 revision – Section 37.5.15 - Third Party Liability/Coordination of Benefits
Pages replaced from 08/30/2022 revision – Table of Contents
Pages replaced from 08/30/2022 revision – Section 37.3 - Reimbursement
Pages replaced from 08/30/2022 revision – Section 37.5 - Appendixes
Pages replaced from 06/27/2022 revision – Section 37.1 – Covered Services, Limitations, and Exclusions
Pages replaced from 01/28/2022 revision – Section 37.0 – Overview
Pages replaced from 01/28/2022 revision – Section 37.1 – Covered Services, Limitations, and Exclusions
Pages replaced from 01/28/2022 revision – Section 37.2 – Provider Requirements and Participation Guidelines
Pages replaced from 01/28/2022 revision – Section 37.3 – Reimbursement
Pages replaced from 01/28/2022 revision – Section 37.4 – Managed Care Applicability
Pages replaced from 01/28/2022 revision – Section 37.5 – Appendixes
Pages replaced from 01/28/2022 revision – Section 37.5.1 – Forms and Links
Pages replaced from 01/28/2022 revision – Section 37.5.2 – Claims Related Information
Pages replaced from 01/28/2022 revision – Section 37.5.3 – Glossary and Acronyms
Pages replaced from 01/28/2022 revision – Section 37.5.4 – Contact Information
Pages replaced from 01/28/2022 revision – Section 37.5.5 – Louisiana Medicaid Preferred Drug List (PDL) and Non-Preferred Drug List (NPDL)
Pages replaced from 01/28/2022 revision – Section 37.5.6 – Prescribers
Pages replaced from 01/28/2022 revision – Section 37.5.7 – Medicare Prescription Drug Coverage
Pages replaced from 01/28/2022 revision – Section 37.5.8 – Claims Submission and Processing Payments
Pages replaced from 01/28/2022 revision – Section 37.5.9 – Public Health Services 340B Drug Pricing Program
Pages replaced from 01/28/2022 revision – Section 37.5.11 – Medication Administration
Pages replaced from 01/28/2022 revision – Section 37.5.12 – Patient Counseling and Drug Utilization Review (DUR)
Pages replaced from 01/28/2022 revision – Section 37.5.13 – Lock-In Program
Pages replaced from 01/28/2022 revision – Section 37.5.14 – Medicaid Drug Rebate Program
Pages replaced from 12/23/2021 revision – Section 37.5.4 – Contact Information
Pages replaced from 08/12/2021 revision – Table of Contents
Pages replaced from 08/12/2021 revision – Section 37.0 – Overview
Pages replaced from 08/12/2021 revision – Section 37.2 – Provider Requirements
Pages replaced from 08/12/2021 revision – Section 37.3 – Reimbursement
Pages replaced from 08/12/2021 revision – Section 37.4 – Managed Care Applicability
Pages replaced from 08/12/2021 revision – Section 37.5.2 – Claims Related Information
Pages replaced from 08/12/2021 revision – Section 37.5.3 – Glossary
Pages replaced from 08/12/2021 revision – Section 37.5.6 – Prescribers
Pages replaced from 08/12/2021 revision – Section 37.5.7 – Medicare Prescription Drug Coverage
Pages replaced from 08/12/2021 revision – Section 37.5.8 – Claims Submission and Processing Payments
Pages replaced from 08/12/2021 revision – Section 37.5.10 – Total Parenteral Nutrition
Pages replaced from 08/12/2021 revision – Section 37.5.12 – Patient Counseling and Drug Utilization Review
Pages replaced from 08/12/2021 revision – Section 37.5.13 – Lock-In Program
Pages replaced from 08/05/2021 revision – Section 37.1 – Covered Services, Limitations and Exclusions
Pages replaced from 07/01/2021 revision – Section 37.1 – Covered Services, Limitations and Exclusions
Pages replaced from 07/01/2021 revision – Section 37.5.3 – Glossary and Acronyms
Pages replaced from 06/24/2021 revision – Section 37.5.11 – Medication Administration
Pages replaced from 05/28/2021 revision – Section 37.5.2 – Claims Related Information
Pages replaced from 04/26/2021 revision – Section 37.1 – Covered Services
Pages replaced from 01/05/2021 revision – Section 37.1 – Covered Services
Pages replaced from 11/06/2020 revision – Section 37.1 – Covered Services
Pages replaced from 05/27/2020 revision – Previous Pharmacy Manual Version
Pages replaced from 02/06/2020 revision – Section 37.1 – Covered Services
Pages replaced from 02/06/2020 revision – Section 37.3 – Reimbursement
Page replaced from 01/14/2020 revision – Title Page
Page replaced from 07/16/2019 revision – Section 37.3 - Reimbursement
Pages replaced from 07/01/2019 revision – Table of Contents
Page replaced from 07/01/2019 revision – Section 37.0 - Overview
Page replaced from 07/01/2019 revision – Section 37.1 – General Program Information
Page replaced from 07/01/2019 revision – Section 37.3 – Medicaid Recipient Eligibility
Pages replaced from 07/01/2019 revision – Section 37.5 – Covered Services, Limitations and Exclusions
Pages replaced from 07/01/2019 revision – Section 37.6 – Reimbursement for Pharmacy Services
Page replaced from 07/01/2019 revision – Appendix A Drugs Payable on Drug File
Page replaced from 07/01/2019 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 07/01/2019 revision – Appendix B DESI Drugs by National Drug Code (NDC) Page replaced from 07/01/2019 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Pages replaced from 07/01/2019 revision – Appendix D Point of Sale User Guide Page replaced from 07/01/2019 revision – Appendix E-1 Products with Quantity Limits Page replaced from 07/01/2019 revision – Appendix E-2 Products with Maximum Daily Dosages Page replaced from 07/01/2019 revision – Appendix F Forms Page replaced from 07/01/2019 revision – Appendix G Universal Claim Form and Instruction Page replaced from 07/01/2019 revision – Appendix H Form 211 – Drug Adjustment/Void Page replaced from 07/01/2019 revision – Appendix I PA01 Form – TPN Prior Authorization Pages replaced from 07/01/2019 revision – Appendix J Claims Filing Page replaced from 07/01/2019 revision – Appendix K Reserved Page replaced from 07/01/2019 revision – Appendix L Tamper Resistant Prescription Criteria and Examples Pages replaced from 07/01/2019 revisions – Appendix M Glossary and Acronyms Pages replaced from 07/01/2019 revision – Appendix N Contact Information Page replaced from 07/01/2019 revision – Appendix O Louisiana Medicaid Single Preferred Drug List (PDL) Prior Authorization List Page replaced from 07/01/2019 revision – Appendix P Diagnosis Code Chart Page replaced from 05/03/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Page replaced from 05/01/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Pages replaced from 09/25/2018 revision – Table of Contents Pages replaced from 09/25/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 09/25/2018 revisions - Appendix F – Forms Page replaced from 09/25/2018 revision – Appendix N – Contact Information Pages replaced from 07/19/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 06/15/2018 revision - Section 37.2 Pharmacy Provider Enrollment and Participation Guidelines Pages replaced from 06/15/2018 revision - Section 37.5: Covered Services, Limitations and Exclusions Pages replaced from 05/07/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 03/29/2018 revision – Table of Contents Pages replaced from 03/29/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Table of Contents Pages replaced from 10/13/12017 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 10/13/2017 revision – Appendix F: Forms Pages replaced from 08/01/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 08/01/2017 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Pages replaced from 04/27/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusion Pages replaced from 03/15/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 01/20/2017 revision – Appendix E-1 Products with Quantity Limits Pages replaced from 01/10/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 11/17/2016 revision – Table of Contents Pages replaced from 11/17/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Title Page Pages replaced from 09/27/2016 revision – Table of Contents Page replaced from 09/27/2016 revision – Overview Page replaced from 09/27/2016 revision – Section 37.1 – General Program Information Pages replaced from 09/27/2016 revision – Section 37.2 – Pharmacy Provider Enrollment and Participation Guidelines Page replaced from 09/27/2016 revision – Section 37.3 – Medicaid Recipient Eligibility Pages replaced from 09/27/2016 revision – Section 37.4 – Prescribers Pages replaced from 09/27/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 09/27/2016 revision – Section 37.6 – Reimbursement for Pharmacy Services Pages replaced from 09/27/2016 revision – Section 37.7 – Medicare Prescription Drug Coverage Pages replaced from 09/27/2016 revision – Section 37.8 – Third Party Liability/Coordination of Benefits Pages replaced from 09/27/2016 revision – Section 37.9 – Claim Submission Pages replaced from 09/27/2016 revision – Section 37.10 – Claims Processing/Payments Pages replaced from 09/27/2016 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 09/27/2016 revision – Section 37.12 – Total Parenteral Nutrition Page replaced from 09/27/2016 revision – Section 37.13 – Reserved Pages replaced from 09/27/2016 revision – Section 37.14 – Medication Administration Pages replaced from 09/27/2016 revision – Section 37.16 – Patient Counseling and Drug Utilization Review (DUR) Pages replaced from 09/27/2016 revision – Section 37.17 – Lock-In Program Page replaced from 09/27/2016 revision – Section 37.18 – Reserved Pages replaced from 09/27/2016 revision – Section 37.19 – Medicaid Fraud and Abuse Pages replaced from 09/27/2016 revision – Section 37.20 – Provider Audits Pages replaced from 09/27/2016 revision – Section 37.21 – Medicaid Drug Rebate Program Pages replaced from 09/27/2016 revision – Section 37.22 – Louisiana Medicaid Website Pages replaced from 09/27/2016 revision - Glossary Pages replaced from 09/27/2016 revision - Acronyms Pages replaced from 09/27/2016 revision - Frequent Contact Information Page replaced from 09/27/2016 revision – Appendix A Drugs Payable on Drug File Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Appendix B DESI Drugs by National Drug Code (NDC) Page replaced from 09/27/2016 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Page replaced from 09/27/2016 revision – Appendix E-1 Products with Quantity Limits Page replaced from 09/27/2016 revision – Appendix E-2 Products with Maximum Daily Dosages Page replaced from 09/27/2016 revision – Appendix F Forms Page replaced from 09/27/2016 revision – Appendix G Universal Claim Form and Instruction Page replaced from 09/27/2016 revision – Appendix H Form 211 – Drug Adjustment/Void Page replaced from 09/27/2016 revision – Appendix I PA01 Form – TPN Prior Authorization Pages replaced from 09/27/2016 revision – Appendix J Claims Filing Page replaced from 09/27/2016 revision – Appendix K Reserved Page replaced from 09/27/2016 revision – Appendix L Tamper Resistant Prescription Criteria and Examples Page replaced from 09/25/2015 revision – Title Page Obsolete Pharmacy Section 37.5 Covered Services, Limitations, and Exclusions (issue date 04/01/11) Obsolete Pharmacy Benefits Management Services, Chapter 37 (issue date 01/01/12) Obsolete Appendix A (issue date 08/15/07) Obsolete Appendix A-1 (issue date 02/19/10) Obsolete Appendix B (issue date 08/15/07) Obsolete Appendix C (issue date 08/15/07) Obsolete Appendix D (issue date 08/15/07) Obsolete Appendix E-1 (issue date 04/01/11) Obsolete Appendix E-2 (issue date 04/01/11) Obsolete Appendix G (issue date 12/01/05) Obsolete Appendix H (issue date 08/15/07) Obsolete Appendix I (issue date 08/15/07) Obsolete Appendix J (issue date 08/15/07) Obsolete Appendix K (issue date 11/01/08) Obsolete Appendix L (issue date 11/01/08) Back
Page replaced from 07/01/2019 revision – Appendix B DESI Drugs by National Drug Code (NDC)
Page replaced from 07/01/2019 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies
Pages replaced from 07/01/2019 revision – Appendix D Point of Sale User Guide Page replaced from 07/01/2019 revision – Appendix E-1 Products with Quantity Limits Page replaced from 07/01/2019 revision – Appendix E-2 Products with Maximum Daily Dosages Page replaced from 07/01/2019 revision – Appendix F Forms Page replaced from 07/01/2019 revision – Appendix G Universal Claim Form and Instruction Page replaced from 07/01/2019 revision – Appendix H Form 211 – Drug Adjustment/Void Page replaced from 07/01/2019 revision – Appendix I PA01 Form – TPN Prior Authorization Pages replaced from 07/01/2019 revision – Appendix J Claims Filing Page replaced from 07/01/2019 revision – Appendix K Reserved Page replaced from 07/01/2019 revision – Appendix L Tamper Resistant Prescription Criteria and Examples Pages replaced from 07/01/2019 revisions – Appendix M Glossary and Acronyms Pages replaced from 07/01/2019 revision – Appendix N Contact Information Page replaced from 07/01/2019 revision – Appendix O Louisiana Medicaid Single Preferred Drug List (PDL) Prior Authorization List Page replaced from 07/01/2019 revision – Appendix P Diagnosis Code Chart Page replaced from 05/03/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Page replaced from 05/01/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Pages replaced from 09/25/2018 revision – Table of Contents Pages replaced from 09/25/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 09/25/2018 revisions - Appendix F – Forms Page replaced from 09/25/2018 revision – Appendix N – Contact Information Pages replaced from 07/19/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 06/15/2018 revision - Section 37.2 Pharmacy Provider Enrollment and Participation Guidelines Pages replaced from 06/15/2018 revision - Section 37.5: Covered Services, Limitations and Exclusions Pages replaced from 05/07/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 03/29/2018 revision – Table of Contents Pages replaced from 03/29/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Table of Contents Pages replaced from 10/13/12017 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 10/13/2017 revision – Appendix F: Forms Pages replaced from 08/01/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 08/01/2017 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Pages replaced from 04/27/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusion Pages replaced from 03/15/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 01/20/2017 revision – Appendix E-1 Products with Quantity Limits Pages replaced from 01/10/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 11/17/2016 revision – Table of Contents Pages replaced from 11/17/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Title Page Pages replaced from 09/27/2016 revision – Table of Contents Page replaced from 09/27/2016 revision – Overview Page replaced from 09/27/2016 revision – Section 37.1 – General Program Information Pages replaced from 09/27/2016 revision – Section 37.2 – Pharmacy Provider Enrollment and Participation Guidelines Page replaced from 09/27/2016 revision – Section 37.3 – Medicaid Recipient Eligibility Pages replaced from 09/27/2016 revision – Section 37.4 – Prescribers Pages replaced from 09/27/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 09/27/2016 revision – Section 37.6 – Reimbursement for Pharmacy Services Pages replaced from 09/27/2016 revision – Section 37.7 – Medicare Prescription Drug Coverage Pages replaced from 09/27/2016 revision – Section 37.8 – Third Party Liability/Coordination of Benefits Pages replaced from 09/27/2016 revision – Section 37.9 – Claim Submission Pages replaced from 09/27/2016 revision – Section 37.10 – Claims Processing/Payments Pages replaced from 09/27/2016 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 09/27/2016 revision – Section 37.12 – Total Parenteral Nutrition Page replaced from 09/27/2016 revision – Section 37.13 – Reserved Pages replaced from 09/27/2016 revision – Section 37.14 – Medication Administration Pages replaced from 09/27/2016 revision – Section 37.16 – Patient Counseling and Drug Utilization Review (DUR) Pages replaced from 09/27/2016 revision – Section 37.17 – Lock-In Program Page replaced from 09/27/2016 revision – Section 37.18 – Reserved Pages replaced from 09/27/2016 revision – Section 37.19 – Medicaid Fraud and Abuse Pages replaced from 09/27/2016 revision – Section 37.20 – Provider Audits Pages replaced from 09/27/2016 revision – Section 37.21 – Medicaid Drug Rebate Program Pages replaced from 09/27/2016 revision – Section 37.22 – Louisiana Medicaid Website Pages replaced from 09/27/2016 revision - Glossary Pages replaced from 09/27/2016 revision - Acronyms Pages replaced from 09/27/2016 revision - Frequent Contact Information Page replaced from 09/27/2016 revision – Appendix A Drugs Payable on Drug File Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Appendix B DESI Drugs by National Drug Code (NDC) Page replaced from 09/27/2016 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Page replaced from 09/27/2016 revision – Appendix E-1 Products with Quantity Limits Page replaced from 09/27/2016 revision – Appendix E-2 Products with Maximum Daily Dosages Page replaced from 09/27/2016 revision – Appendix F Forms Page replaced from 09/27/2016 revision – Appendix G Universal Claim Form and Instruction Page replaced from 09/27/2016 revision – Appendix H Form 211 – Drug Adjustment/Void Page replaced from 09/27/2016 revision – Appendix I PA01 Form – TPN Prior Authorization Pages replaced from 09/27/2016 revision – Appendix J Claims Filing Page replaced from 09/27/2016 revision – Appendix K Reserved Page replaced from 09/27/2016 revision – Appendix L Tamper Resistant Prescription Criteria and Examples Page replaced from 09/25/2015 revision – Title Page Obsolete Pharmacy Section 37.5 Covered Services, Limitations, and Exclusions (issue date 04/01/11) Obsolete Pharmacy Benefits Management Services, Chapter 37 (issue date 01/01/12) Obsolete Appendix A (issue date 08/15/07) Obsolete Appendix A-1 (issue date 02/19/10) Obsolete Appendix B (issue date 08/15/07) Obsolete Appendix C (issue date 08/15/07) Obsolete Appendix D (issue date 08/15/07) Obsolete Appendix E-1 (issue date 04/01/11) Obsolete Appendix E-2 (issue date 04/01/11) Obsolete Appendix G (issue date 12/01/05) Obsolete Appendix H (issue date 08/15/07) Obsolete Appendix I (issue date 08/15/07) Obsolete Appendix J (issue date 08/15/07) Obsolete Appendix K (issue date 11/01/08) Obsolete Appendix L (issue date 11/01/08) Back
Page replaced from 07/01/2019 revision – Appendix E-1 Products with Quantity Limits
Page replaced from 07/01/2019 revision – Appendix E-2 Products with Maximum Daily Dosages
Page replaced from 07/01/2019 revision – Appendix F Forms
Page replaced from 07/01/2019 revision – Appendix G Universal Claim Form and Instruction
Page replaced from 07/01/2019 revision – Appendix H Form 211 – Drug Adjustment/Void
Page replaced from 07/01/2019 revision – Appendix I PA01 Form – TPN Prior Authorization
Pages replaced from 07/01/2019 revision – Appendix J Claims Filing
Page replaced from 07/01/2019 revision – Appendix K Reserved Page replaced from 07/01/2019 revision – Appendix L Tamper Resistant Prescription Criteria and Examples Pages replaced from 07/01/2019 revisions – Appendix M Glossary and Acronyms Pages replaced from 07/01/2019 revision – Appendix N Contact Information Page replaced from 07/01/2019 revision – Appendix O Louisiana Medicaid Single Preferred Drug List (PDL) Prior Authorization List Page replaced from 07/01/2019 revision – Appendix P Diagnosis Code Chart Page replaced from 05/03/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Page replaced from 05/01/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Pages replaced from 09/25/2018 revision – Table of Contents Pages replaced from 09/25/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 09/25/2018 revisions - Appendix F – Forms Page replaced from 09/25/2018 revision – Appendix N – Contact Information Pages replaced from 07/19/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 06/15/2018 revision - Section 37.2 Pharmacy Provider Enrollment and Participation Guidelines Pages replaced from 06/15/2018 revision - Section 37.5: Covered Services, Limitations and Exclusions Pages replaced from 05/07/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 03/29/2018 revision – Table of Contents Pages replaced from 03/29/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Table of Contents Pages replaced from 10/13/12017 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 10/13/2017 revision – Appendix F: Forms Pages replaced from 08/01/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 08/01/2017 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Pages replaced from 04/27/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusion Pages replaced from 03/15/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 01/20/2017 revision – Appendix E-1 Products with Quantity Limits Pages replaced from 01/10/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 11/17/2016 revision – Table of Contents Pages replaced from 11/17/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Title Page Pages replaced from 09/27/2016 revision – Table of Contents Page replaced from 09/27/2016 revision – Overview Page replaced from 09/27/2016 revision – Section 37.1 – General Program Information Pages replaced from 09/27/2016 revision – Section 37.2 – Pharmacy Provider Enrollment and Participation Guidelines Page replaced from 09/27/2016 revision – Section 37.3 – Medicaid Recipient Eligibility Pages replaced from 09/27/2016 revision – Section 37.4 – Prescribers Pages replaced from 09/27/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 09/27/2016 revision – Section 37.6 – Reimbursement for Pharmacy Services Pages replaced from 09/27/2016 revision – Section 37.7 – Medicare Prescription Drug Coverage Pages replaced from 09/27/2016 revision – Section 37.8 – Third Party Liability/Coordination of Benefits Pages replaced from 09/27/2016 revision – Section 37.9 – Claim Submission Pages replaced from 09/27/2016 revision – Section 37.10 – Claims Processing/Payments Pages replaced from 09/27/2016 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 09/27/2016 revision – Section 37.12 – Total Parenteral Nutrition Page replaced from 09/27/2016 revision – Section 37.13 – Reserved Pages replaced from 09/27/2016 revision – Section 37.14 – Medication Administration Pages replaced from 09/27/2016 revision – Section 37.16 – Patient Counseling and Drug Utilization Review (DUR) Pages replaced from 09/27/2016 revision – Section 37.17 – Lock-In Program Page replaced from 09/27/2016 revision – Section 37.18 – Reserved Pages replaced from 09/27/2016 revision – Section 37.19 – Medicaid Fraud and Abuse Pages replaced from 09/27/2016 revision – Section 37.20 – Provider Audits Pages replaced from 09/27/2016 revision – Section 37.21 – Medicaid Drug Rebate Program Pages replaced from 09/27/2016 revision – Section 37.22 – Louisiana Medicaid Website Pages replaced from 09/27/2016 revision - Glossary Pages replaced from 09/27/2016 revision - Acronyms Pages replaced from 09/27/2016 revision - Frequent Contact Information Page replaced from 09/27/2016 revision – Appendix A Drugs Payable on Drug File Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Appendix B DESI Drugs by National Drug Code (NDC) Page replaced from 09/27/2016 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Page replaced from 09/27/2016 revision – Appendix E-1 Products with Quantity Limits Page replaced from 09/27/2016 revision – Appendix E-2 Products with Maximum Daily Dosages Page replaced from 09/27/2016 revision – Appendix F Forms Page replaced from 09/27/2016 revision – Appendix G Universal Claim Form and Instruction Page replaced from 09/27/2016 revision – Appendix H Form 211 – Drug Adjustment/Void Page replaced from 09/27/2016 revision – Appendix I PA01 Form – TPN Prior Authorization Pages replaced from 09/27/2016 revision – Appendix J Claims Filing Page replaced from 09/27/2016 revision – Appendix K Reserved Page replaced from 09/27/2016 revision – Appendix L Tamper Resistant Prescription Criteria and Examples Page replaced from 09/25/2015 revision – Title Page Obsolete Pharmacy Section 37.5 Covered Services, Limitations, and Exclusions (issue date 04/01/11) Obsolete Pharmacy Benefits Management Services, Chapter 37 (issue date 01/01/12) Obsolete Appendix A (issue date 08/15/07) Obsolete Appendix A-1 (issue date 02/19/10) Obsolete Appendix B (issue date 08/15/07) Obsolete Appendix C (issue date 08/15/07) Obsolete Appendix D (issue date 08/15/07) Obsolete Appendix E-1 (issue date 04/01/11) Obsolete Appendix E-2 (issue date 04/01/11) Obsolete Appendix G (issue date 12/01/05) Obsolete Appendix H (issue date 08/15/07) Obsolete Appendix I (issue date 08/15/07) Obsolete Appendix J (issue date 08/15/07) Obsolete Appendix K (issue date 11/01/08) Obsolete Appendix L (issue date 11/01/08) Back
Page replaced from 07/01/2019 revision – Appendix L Tamper Resistant Prescription Criteria and Examples
Pages replaced from 07/01/2019 revisions – Appendix M Glossary and Acronyms
Pages replaced from 07/01/2019 revision – Appendix N Contact Information Page replaced from 07/01/2019 revision – Appendix O Louisiana Medicaid Single Preferred Drug List (PDL) Prior Authorization List Page replaced from 07/01/2019 revision – Appendix P Diagnosis Code Chart Page replaced from 05/03/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Page replaced from 05/01/2019 revision – Appendix O – Preferred Drug List/Prior Authorization Pages replaced from 09/25/2018 revision – Table of Contents Pages replaced from 09/25/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 09/25/2018 revisions - Appendix F – Forms Page replaced from 09/25/2018 revision – Appendix N – Contact Information Pages replaced from 07/19/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 06/15/2018 revision - Section 37.2 Pharmacy Provider Enrollment and Participation Guidelines Pages replaced from 06/15/2018 revision - Section 37.5: Covered Services, Limitations and Exclusions Pages replaced from 05/07/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 03/29/2018 revision – Table of Contents Pages replaced from 03/29/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Table of Contents Pages replaced from 10/13/12017 revision – Section 37.5 – Covered Services, Limitations, and Exclusions Pages replaced from 10/13/2017 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 10/13/2017 revision – Appendix F: Forms Pages replaced from 08/01/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 08/01/2017 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Pages replaced from 04/27/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusion Pages replaced from 03/15/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 01/20/2017 revision – Appendix E-1 Products with Quantity Limits Pages replaced from 01/10/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 11/17/2016 revision – Table of Contents Pages replaced from 11/17/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Title Page Pages replaced from 09/27/2016 revision – Table of Contents Page replaced from 09/27/2016 revision – Overview Page replaced from 09/27/2016 revision – Section 37.1 – General Program Information Pages replaced from 09/27/2016 revision – Section 37.2 – Pharmacy Provider Enrollment and Participation Guidelines Page replaced from 09/27/2016 revision – Section 37.3 – Medicaid Recipient Eligibility Pages replaced from 09/27/2016 revision – Section 37.4 – Prescribers Pages replaced from 09/27/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions Pages replaced from 09/27/2016 revision – Section 37.6 – Reimbursement for Pharmacy Services Pages replaced from 09/27/2016 revision – Section 37.7 – Medicare Prescription Drug Coverage Pages replaced from 09/27/2016 revision – Section 37.8 – Third Party Liability/Coordination of Benefits Pages replaced from 09/27/2016 revision – Section 37.9 – Claim Submission Pages replaced from 09/27/2016 revision – Section 37.10 – Claims Processing/Payments Pages replaced from 09/27/2016 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program Pages replaced from 09/27/2016 revision – Section 37.12 – Total Parenteral Nutrition Page replaced from 09/27/2016 revision – Section 37.13 – Reserved Pages replaced from 09/27/2016 revision – Section 37.14 – Medication Administration Pages replaced from 09/27/2016 revision – Section 37.16 – Patient Counseling and Drug Utilization Review (DUR) Pages replaced from 09/27/2016 revision – Section 37.17 – Lock-In Program Page replaced from 09/27/2016 revision – Section 37.18 – Reserved Pages replaced from 09/27/2016 revision – Section 37.19 – Medicaid Fraud and Abuse Pages replaced from 09/27/2016 revision – Section 37.20 – Provider Audits Pages replaced from 09/27/2016 revision – Section 37.21 – Medicaid Drug Rebate Program Pages replaced from 09/27/2016 revision – Section 37.22 – Louisiana Medicaid Website Pages replaced from 09/27/2016 revision - Glossary Pages replaced from 09/27/2016 revision - Acronyms Pages replaced from 09/27/2016 revision - Frequent Contact Information Page replaced from 09/27/2016 revision – Appendix A Drugs Payable on Drug File Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates Page replaced from 09/27/2016 revision – Appendix B DESI Drugs by National Drug Code (NDC) Page replaced from 09/27/2016 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies Page replaced from 09/27/2016 revision – Appendix E-1 Products with Quantity Limits Page replaced from 09/27/2016 revision – Appendix E-2 Products with Maximum Daily Dosages Page replaced from 09/27/2016 revision – Appendix F Forms Page replaced from 09/27/2016 revision – Appendix G Universal Claim Form and Instruction Page replaced from 09/27/2016 revision – Appendix H Form 211 – Drug Adjustment/Void Page replaced from 09/27/2016 revision – Appendix I PA01 Form – TPN Prior Authorization Pages replaced from 09/27/2016 revision – Appendix J Claims Filing Page replaced from 09/27/2016 revision – Appendix K Reserved Page replaced from 09/27/2016 revision – Appendix L Tamper Resistant Prescription Criteria and Examples Page replaced from 09/25/2015 revision – Title Page Obsolete Pharmacy Section 37.5 Covered Services, Limitations, and Exclusions (issue date 04/01/11) Obsolete Pharmacy Benefits Management Services, Chapter 37 (issue date 01/01/12) Obsolete Appendix A (issue date 08/15/07) Obsolete Appendix A-1 (issue date 02/19/10) Obsolete Appendix B (issue date 08/15/07) Obsolete Appendix C (issue date 08/15/07) Obsolete Appendix D (issue date 08/15/07) Obsolete Appendix E-1 (issue date 04/01/11) Obsolete Appendix E-2 (issue date 04/01/11) Obsolete Appendix G (issue date 12/01/05) Obsolete Appendix H (issue date 08/15/07) Obsolete Appendix I (issue date 08/15/07) Obsolete Appendix J (issue date 08/15/07) Obsolete Appendix K (issue date 11/01/08) Obsolete Appendix L (issue date 11/01/08) Back
Page replaced from 07/01/2019 revision – Appendix O Louisiana Medicaid Single Preferred Drug List (PDL) Prior Authorization List
Page replaced from 07/01/2019 revision – Appendix P Diagnosis Code Chart
Page replaced from 05/03/2019 revision – Appendix O – Preferred Drug List/Prior Authorization
Page replaced from 05/01/2019 revision – Appendix O – Preferred Drug List/Prior Authorization
Pages replaced from 09/25/2018 revision – Table of Contents
Pages replaced from 09/25/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions
Pages replaced from 09/25/2018 revisions - Appendix F – Forms
Page replaced from 09/25/2018 revision – Appendix N – Contact Information
Pages replaced from 07/19/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions
Pages replaced from 06/15/2018 revision - Section 37.2 Pharmacy Provider Enrollment and Participation Guidelines
Pages replaced from 06/15/2018 revision - Section 37.5: Covered Services, Limitations and Exclusions
Pages replaced from 05/07/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions
Pages replaced from 03/29/2018 revision – Table of Contents
Pages replaced from 03/29/2018 revision – Section 37.5 – Covered Services, Limitations, and Exclusions
Pages replaced from 10/13/2017 revision – Table of Contents
Pages replaced from 10/13/12017 revision – Section 37.5 – Covered Services, Limitations, and Exclusions
Pages replaced from 10/13/2017 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program
Pages replaced from 10/13/2017 revision – Appendix F: Forms
Pages replaced from 08/01/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions
Page replaced from 08/01/2017 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies
Pages replaced from 04/27/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusion
Pages replaced from 03/15/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions
Page replaced from 01/20/2017 revision – Appendix E-1 Products with Quantity Limits
Pages replaced from 01/10/2017 revision – Section 37.5 – Covered Services, Limitations and Exclusions
Pages replaced from 11/17/2016 revision – Table of Contents
Pages replaced from 11/17/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions
Page replaced from 09/27/2016 revision – Appendix A-1 List of Drugs with Average Acquisition Rates
Page replaced from 09/27/2016 revision – Title Page
Pages replaced from 09/27/2016 revision – Table of Contents
Page replaced from 09/27/2016 revision – Overview
Page replaced from 09/27/2016 revision – Section 37.1 – General Program Information
Pages replaced from 09/27/2016 revision – Section 37.2 – Pharmacy Provider Enrollment and Participation Guidelines
Page replaced from 09/27/2016 revision – Section 37.3 – Medicaid Recipient Eligibility
Pages replaced from 09/27/2016 revision – Section 37.4 – Prescribers
Pages replaced from 09/27/2016 revision – Section 37.5 – Covered Services, Limitations and Exclusions
Pages replaced from 09/27/2016 revision – Section 37.6 – Reimbursement for Pharmacy Services
Pages replaced from 09/27/2016 revision – Section 37.7 – Medicare Prescription Drug Coverage
Pages replaced from 09/27/2016 revision – Section 37.8 – Third Party Liability/Coordination of Benefits
Pages replaced from 09/27/2016 revision – Section 37.9 – Claim Submission
Pages replaced from 09/27/2016 revision – Section 37.10 – Claims Processing/Payments
Pages replaced from 09/27/2016 revision – Section 37.11 – Public Health Services 340B Drug Pricing Program
Pages replaced from 09/27/2016 revision – Section 37.12 – Total Parenteral Nutrition
Page replaced from 09/27/2016 revision – Section 37.13 – Reserved
Pages replaced from 09/27/2016 revision – Section 37.14 – Medication Administration
Pages replaced from 09/27/2016 revision – Section 37.16 – Patient Counseling and Drug Utilization Review (DUR)
Pages replaced from 09/27/2016 revision – Section 37.17 – Lock-In Program
Page replaced from 09/27/2016 revision – Section 37.18 – Reserved
Pages replaced from 09/27/2016 revision – Section 37.19 – Medicaid Fraud and Abuse
Pages replaced from 09/27/2016 revision – Section 37.20 – Provider Audits
Pages replaced from 09/27/2016 revision – Section 37.21 – Medicaid Drug Rebate Program
Pages replaced from 09/27/2016 revision – Section 37.22 – Louisiana Medicaid Website
Pages replaced from 09/27/2016 revision - Glossary
Pages replaced from 09/27/2016 revision - Acronyms
Pages replaced from 09/27/2016 revision - Frequent Contact Information
Page replaced from 09/27/2016 revision – Appendix A Drugs Payable on Drug File
Page replaced from 09/27/2016 revision – Appendix B DESI Drugs by National Drug Code (NDC)
Page replaced from 09/27/2016 revision – Appendix C Medicaid Drug Federal Rebate Participation Pharmaceutical Companies
Page replaced from 09/27/2016 revision – Appendix E-1 Products with Quantity Limits
Page replaced from 09/27/2016 revision – Appendix E-2 Products with Maximum Daily Dosages
Page replaced from 09/27/2016 revision – Appendix F Forms
Page replaced from 09/27/2016 revision – Appendix G Universal Claim Form and Instruction
Page replaced from 09/27/2016 revision – Appendix H Form 211 – Drug Adjustment/Void
Page replaced from 09/27/2016 revision – Appendix I PA01 Form – TPN Prior Authorization
Pages replaced from 09/27/2016 revision – Appendix J Claims Filing
Page replaced from 09/27/2016 revision – Appendix K Reserved
Page replaced from 09/27/2016 revision – Appendix L Tamper Resistant Prescription Criteria and Examples
Page replaced from 09/25/2015 revision – Title Page
Obsolete Pharmacy Section 37.5 Covered Services, Limitations, and Exclusions (issue date 04/01/11)
Obsolete Pharmacy Benefits Management Services, Chapter 37 (issue date 01/01/12)
Obsolete Appendix A (issue date 08/15/07)
Obsolete Appendix A-1 (issue date 02/19/10)
Obsolete Appendix B (issue date 08/15/07)
Obsolete Appendix C (issue date 08/15/07)
Obsolete Appendix D (issue date 08/15/07)
Obsolete Appendix E-1 (issue date 04/01/11)
Obsolete Appendix E-2 (issue date 04/01/11)
Obsolete Appendix G (issue date 12/01/05)
Obsolete Appendix H (issue date 08/15/07)
Obsolete Appendix I (issue date 08/15/07)
Obsolete Appendix J (issue date 08/15/07)
Obsolete Appendix K (issue date 11/01/08)
Obsolete Appendix L (issue date 11/01/08)
Back