PHARMACY PROVIDERS, PLEASE NOTE!!!

If you are unsure about the coverage of a drug product, please contact the PBM help desk at 1-800-648-0790.

Please file adjustments for claims that may have been incorrectly paid. Only those products of the manufacturers which participate in the Federal Rebate Program will be covered by the Medicaid program. Participation may be verified in Appendix C, available at http://www.lamedicaid.com. 

Should you have any questions regarding any of the following messages, please contact Gainwell Technologies at (800) 473-2783 or (225) 924-5040.

For information regarding the medication policy and/or criteria associated with this denial, providers may access the Louisiana Medicaid Preferred Drug List (PDL) / Non-Preferred Drug List at http://ldh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf.

Transcranial Magnetic Stimulation

Effective August 2, 2024, Louisiana Medicaid covers Transcranial Magnetic Stimulation (TMS) in accordance with FDA approval for major depression only.

TMS is a noninvasive method of delivering electrical stimulation to the brain. A magnetic field is delivered through the skull, where it induces electric currents that affect neuronal function. TMS can be performed in an office setting as it does not require anesthesia and does not induce a convulsion.

TMS is considered medically necessary when ALL of the following criteria are met:

  1. Member is 18 years of age or older; AND
  2. Diagnosis of major depressive disorder (DSM 5 diagnostic terminology); AND
  3. Failure of a full course of evidence-based psychotherapy, such as cognitive behavioral therapy for the current depressive episode; AND
  4. Failure or intolerance to psychopharmacologic agents, choose ONE of the following:
  5. Failure of psychopharmacologic agents, BOTH of the following:
  6. Lack of clinically significant response in the current depressive episode to four trials of agents from at least two different agent classes; AND
  7. At least two of the treatment trials were administered as an adequate course of mono- or poly-drug therapy with antidepressants, involving standard therapeutic doses of at least 6 weeks duration.

The member is unable to take anti-depressants due to ONE of the following:

  1. Drug interactions with medically necessary medications; OR
  2. Inability to tolerate psychopharmacologic agents, as evidenced by trials of four such agents with distinct side effects in the current episode; AND
  3. No contraindications to TMS are present (see section on contraindications); AND
  4. Electroconvulsive therapy has previously been attempted, is medically contraindicated, or has been offered and declined by the member.

Questions regarding this message and Fee-For-Service claims are to be directed to Gainwell Technologies Provider Relations at (800) 473-2783 or (225) 924-5040.

Screening Mammography

Effective June 1, 2024, Louisiana Medicaid allows payment for one screening mammogram (either film or digital) per calendar year for beneficiaries meeting one or more of the following criteria:

  • Any woman age 30 or older with hereditary susceptibility from pathogenic mutation carrier status or prior chest wall radiation.
  • Provider recommendation for any woman 35 years of age or older with a predicted lifetime risk greater than twenty percent.
  • Any woman who is 35 through 39 years of age. Please Note: Only one baseline mammogram allowable between this age range for beneficiaries not meeting other criteria.
  • Any woman who is 40 years of age or older.

Questions regarding this message and Fee-For-Service claims are to be directed to Gainwell Technologies Provider Relations at (800) 473-2783 or (225) 924-5040.