Changes to Medicaid Pharmacy Benefit Management

On October 1, 2025, the pharmacy benefit manager (PBM) for most Medicaid members will change. Medicaid will discontinue its single PBM and each health plan will handle pharmacy services for their members, including prior authorizations, claims and prescription coverage.

This change does not apply to fee-for-service (FFS) members or people who have behavioral-health-only coverage through their Medicaid health plan.
FFS pharmacy will continue to be processed by Gainwell, and prior authorizations will still be managed by the University of Louisiana at Monroe.

What You Need to Know – Medicaid Members Enrolled in a Health Plan

• Most members will get a new health plan ID card.
  • Your health plan will mail you the new card.
  • The pharmacy information and phone number will be updated.
  • Start using your new card to fill prescriptions beginning October 1, 2025. You may need to remind the pharmacist that you have new pharmacy information on your card.

• Your benefits are not changing.
  • Your co-pays will remain the same.
  • Prior authorizations will continue to be honored. No action is needed.
  • All Medicaid health plans will still follow the Louisiana Medicaid preferred drug list.

• Your pharmacy network might change.
  • Most pharmacies will be in network, but some may not be.
  • Your health plan will contact you if you are using a pharmacy that will no longer be in network.
• Questions? Call your health plan.

 

What You Need to Know – Pharmacies Accepting Medicaid

• Before October 1, 2025, continue to operate as normal with Prime Therapeutics as the Healthy Louisiana single PBM.
• Prior Authorizations: Existing prior authorizations will be transferred to the new PBMs and will continue to be honored.
• Networks: Confirm your pharmacy’s network status with each health plan PBM.
• New ID Cards: All affected Medicaid enrollees will be mailed new health plan ID cards containing updated PBM details. During the transition, some Medicaid enrollees may present ID cards with incorrect PBM details. You can find the correct information on this PBM transition flyer.
• Fee-for-Service: Medicaid enrollees covered under the fee-for-service program are not affected by this transition.

Questions? Talk to your health plan PBM or submit them to Medicaid here.