Medicaid Pharmacy Benefits Management
Louisiana Medicaid Pharmacy Benefits Management Program is the first state-owned and administered Pharmacy Benefit Management (PBM) system for Medicaid in the nation. Prescription services are one of the largest service and expenditure areas under the Medicaid program, and this section coordinates all Medicaid pharmacy-related services.
Contact the Medicaid Pharmacy Benefits Management Program at 1.800.437.9101 or email Healthy@la.gov.
Federal and state laws and regulations require Medicaid to ensure the integrity of the pharmacy program through various monitoring, review and audit mechanisms. The Pharmacy Benefits Management Program section is responsible for auditing Medicaid pharmacy providers to ensure that they are billing and being reimbursed in compliance with federal and state laws and regulations and Louisiana Medicaid Pharmacy Program policy. This function is performed by conducting desk audits and annual field audits of providers, and auditing pharmacies for multiple types of discrepancies to identify paid pharmacy claims that may be out of compliance with Medicaid rules and policies. This review ensures the review of paid claims on a timely basis, resulting in quicker corrective action by the provider.
Each provider upon enrolling in the Title XIX Medicaid Program agrees to dispense prescriptions and operate within the program’s laws and regulations as set forth in the Louisiana Medicaid Program Provider Manual and other directives.
In an effort to facilitate the pharmacy audit process, information must be available upon request. This information is necessary in order to comply with the requirements for a pharmacy services provider enrolled in Louisiana’s Medicaid Program as stated in the PE-50 (Provider Enrollment Form) and to meet the requirements of the Louisiana State Board of Pharmacy. Providers are required to refund overpayments identified by the audits and take appropriate corrective action.
At the time of audit, all Medicaid pharmacy providers must be able to produce a daily log, or prescription register. This daily log, whether routinely produced in hard copy or producible in hard copy at the time of audit, must contain at a minimum, for audit purposes, the following prescription data:
- Prescription number;
- Indicator as to new or refill prescription (0-5)
- Date of dispensing
- Patient's name;
- Prescriber's name;
- Drug name;
- NDC number
- Quantity dispensed;
- Plan identifier indicating case or plan making payment; and
- Amound paid (including both copayment and plan payment, which may or may not be separated, e.g. AMOUNT PAID = AMOUNT PLAN PAID + AMOUNT PATIENT PAID.)
The Medicaid program administers a prior authorization process for services in its Pharmacy Benefits Management System. The Prescription Prior Authorization (RxPA) operations are operated by the University of Louisiana at Monroe College of Pharmacy - Office of Outcomes Research and Evaluation.
The RxPA process uses a preferred drug list (PDL) for selected therapeutic classes. Drugs included on the PDL are automatically prior authorized. Drugs in these classes that are not included on the PDL require prescribers to obtain prior authorization.
Providers are notified of the drugs selected for placement on the PDL by therapeutic classes prior to implementation of the prior authorization process and as additional drugs are added to the list. Lists of covered drug products, including those that require prior authorization, will be provided through Medicaid.
Medicaid Pharmacy Benefits Managment Resources