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| Item Number | Policy/Procedure | Date Posted | Comment Period Closed | Status | Document Links |
|---|---|---|---|---|---|
| 2024-LHCC-MED-683 | Degarelix Acetate (Firmagon) | 1/9/25 | 2/23/25 | Pending | Degarelix Acetate (Firmagon) |
| 2024-LHCC-MED-684 | Belatacept (Nulojix) | 1/9/25 | 2/23/25 | Pending | Belatacept (Nulojix) |
| 2024-LHCC-MED-685 | Immunization coverage | 1/9/25 | 2/23/25 | Pending | Immunization coverage |
| 2024-LHCC-MED-686 | Eribulin Mesylate (Halaven) | 1/9/25 | 2/23/25 | Pending | Eribulin Mesylate (Halaven) |
| 2024-LHCC-MED-687 | Necitumumab (Portrazza) | 1/9/25 | 2/23/25 | Pending | Necitumumab (Portrazza) |
| 2024-LHCC-MED-688 | Ziv-aflibercept (Zaltrap) | 1/9/25 | 2/23/25 | Pending | Ziv-aflibercept (Zaltrap) |
| 2024-LHCC-MED-689 | Daunorubicin/Cytarabine (Vyxeos) | 1/9/25 | 2/23/25 | Pending | Daunorubicin/Cytarabine (Vyxeos) |
| 2024-LHCC-MED-690 | Leucovorin Injection | 1/9/25 | 2/23/25 | Pending | Leucovorin Injection |
| 2024-LHCC-MED-691 | Pegunigalsidase alfa-iwxj (Elfabrio) | 1/9/25 | 2/23/25 | Pending | Pegunigalsidase alfa-iwxj (Elfabrio) |
| 2024-LHCC-MED-692 | Plasminogen, Human-tvmh (Ryplazim) | 1/9/25 | 2/23/25 | Pending | Plasminogen, Human-tvmh (Ryplazim) |
| 2024-LHCC-MED-693 | Tofersen (Qalsody) | 1/9/25 | 2/23/25 | Pending | Tofersen (Qalsody) |
| 2024-LHCC-MED-694 | Velmanase Alfa-tycv (Lamzede) | 1/9/25 | 2/23/25 | Pending | Velmanase Alfa-tycv (Lamzede) |
| 2024-LHCC-MED-678 | Pasireotide (Signifor, Signifor LAR) | 1/9/25 | 2/23/25 | Pending | Pasireotide (Signifor, Signifor LAR) |
| 2024-LHCC-MED-679 | Copanlisib (Aliqopa) | 1/9/25 | 2/23/25 | Pending | Copanlisib (Aliqopa) |
| 2024-LHCC-MED-680 | Pegvisomant (Somavert) | 1/9/25 | 2/23/25 | Pending | Pegvisomant (Somavert) |
| 2024-LHCC-MED-681 | Lanreotide (Somatuline Depot) | 1/9/25 | 2/23/25 | Pending | Lanreotide (Somatuline Depot) |
| 2024-LHCC-MED-682 | Pegcetacoplan (Empaveli, Syfovre) | 1/9/25 | 2/23/25 | Pending | Pegcetacoplan (Empaveli, Syfovre) |
| 2025-UHC-MED-228 | Oncology medication clinical coverage | 1/8/25 | 2/22/25 | Pending | Oncology medication clinical coverage |
| 2025-UHC-MED-229 | Provider administered drugs site of care | 1/8/25 | 2/22/25 | Pending | Provider administered drugs site of care |
| 2025-UHC-MED-230 | Botulinum toxins a and b | 1/8/25 | 2/22/25 | Pending | Botulinum toxins a and b |
| 2025-UHC-MED-231 | Iron replacement therapy | 1/8/25 | 2/22/25 | Pending | Iron replacement therapy |
| 2025-UHC-MED-232 | Tepezza | 1/8/25 | 2/22/25 | Pending | Tepezza |
| 2025-HB-MED-490 | Tecelra | 1/8/25 | 2/22/25 | Pending | Tecelra |
| 2025-HB-MED-491 | Niktimvo | 1/8/25 | 2/22/25 | Pending | Niktimvo |
| 2025-HB-MED-493 | Lymphir | 1/8/25 | 2/22/25 | Pending | Lymphir |
| 2025-LHCC-MED-632 | Sotatercept (Winrevair) | 1/8/25 | 2/22/25 | Pending | Sotatercept (Winrevair) |
| 2025-PHARM-1 | Aqneursa | 1/8/25 | 2/22/25 | Pending | Aqneursa |
| 2025-PHARM-2 | Asthma, Immunomodulators | 1/8/25 | 2/22/25 | Pending | Asthma, Immunomodulators |
| 2025-PHARM-3 | Colony Stimulating Factors | 1/8/25 | 2/22/25 | Pending | Colony Stimulating Factors |
| 2025-PHARM-4 | Dermatology - Atopic Dermatitis, Immunomodulators | 1/8/25 | 2/22/25 | Pending | Dermatology - Atopic Dermatitis, Immunomodulators |
| 2025-PHARM-5 | Duvyzat | 1/8/25 | 2/22/25 | Pending | Duvyzat |
| 2025-PHARM-6 | Ebglyss | 1/8/25 | 2/22/25 | Pending | Ebglyss |
| 2025-PHARM-7 | Lodoco | 1/8/25 | 2/22/25 | Pending | Lodoco |
| 2025-PHARM-8 | Louisiana Medicaid ICD-10 Chart | 1/8/25 | 2/22/25 | Pending | Louisiana Medicaid ICD-10 Chart |
| 2025-PHARM-9 | Max Dose Override Buprenorphine | 1/8/25 | 2/22/25 | Pending | Max Dose Override Buprenorphine |
| 2025-PHARM-10 | Miplyffa | 1/8/25 | 2/22/25 | Pending | Miplyffa |
| 2025-PHARM-11 | Narcotics Quantity Limit and MME Override | 1/8/25 | 2/22/25 | Pending | Narcotics Quantity Limit and MME Override |
| 2025-PHARM-12 | Nemluvio | 1/8/25 | 2/22/25 | Pending | Nemluvio |
| 2025-PHARM-13 | Ocrevus Zunovo | 1/8/25 | 2/22/25 | Pending | Ocrevus Zunovo |
| 2025-PHARM-14 | Pain Management, Cytokine and CAM Antagonists | 1/8/25 | 2/22/25 | Pending | Pain Management, Cytokine and CAM Antagonists |
| 2025-PHARM-15 | Pain Management, LA Narcotic Analgesics | 1/8/25 | 2/22/25 | Pending | Pain Management, LA Narcotic Analgesics |
| 2025-PHARM-16 | Pain Management, SA Narcotic Analgesics | 1/8/25 | 2/22/25 | Pending | Pain Management, SA Narcotic Analgesics |
| 2025-PHARM-17 | POS ADD-ADHD Stimulants and Related Agents | 1/8/25 | 2/22/25 | Pending | POS ADD-ADHD Stimulants and Related Agents |
| 2025-PHARM-18 | POS Anticonvulsants | 1/8/25 | 2/22/25 | Pending | POS Anticonvulsants |
| 2025-PHARM-19 | POS Asthma - COPD, Glucocorticoids Inhalation | 1/8/25 | 2/22/25 | Pending | POS Asthma - COPD, Glucocorticoids Inhalation |
| 2025-PHARM-20 | POS Cobenfy | 1/8/25 | 2/22/25 | Pending | POS Cobenfy |
| 2025-PHARM-21 | POS Dermatology - Antibiotics, Topical | 1/8/25 | 2/22/25 | Pending | POS Dermatology - Antibiotics, Topical |
| 2025-PHARM-22 | POS Dermatology - Atopic Dermatitis, Immunomodulators | 1/8/25 | 2/22/25 | Pending | POS Dermatology - Atopic Dermatitis, Immunomodulators |
| 2025-PHARM-23 | POS Diabetes - Hypoglycemics, Incretin Mimetics/Enhancers | 1/8/25 | 2/22/25 | Pending | POS Diabetes - Hypoglycemics, Incretin Mimetics/Enhancers |
| 2025-PHARM-24 | POS Diabetes - Hypoglycemics, Insulins and Related Agents | 1/8/25 | 2/22/25 | Pending | POS Diabetes - Hypoglycemics, Insulins and Related Agents |
| 2025-PHARM-25 | POS Erzofri | 1/8/25 | 2/22/25 | Pending | POS Erzofri |
| 2025-PHARM-26 | POS GI Motility Chronic | 1/8/25 | 2/22/25 | Pending | POS GI Motility Chronic |
| 2025-PHARM-27 | POS Lodoco | 1/8/25 | 2/22/25 | Pending | POS Lodoco |
| 2025-PHARM-28 | POS Neffy | 1/8/25 | 2/22/25 | Pending | POS Neffy |
| 2025-PHARM-29 | POS Ophthalmic Disorders, Anti-Inflammatory Immunomodulators | 1/8/25 | 2/22/25 | Pending | POS Ophthalmic Disorders, Anti-Inflammatory Immunomodulators |
| 2025-PHARM-30 | POS Opiate Dependence Agents | 1/8/25 | 2/22/25 | Pending | POS Opiate Dependence Agents |
| 2025-PHARM-31 | POS Pain Management - Antimigraine Agents, CGRP Antagonists | 1/8/25 | 2/22/25 | Pending | POS Pain Management - Antimigraine Agents, CGRP Antagonists |
| 2025-PHARM-32 | Vyondys | 1/8/25 | 2/22/25 | Pending | Vyondys |
| 2024-HB-MED-486 | Botulinum Toxin | 12/13/24 | 1/27/25 | Pending | Botulinum Toxin |
| 2024-LHCC-MED-675 | Axatilimab-csfr (Niktimvo) | 12/13/24 | 1/27/25 | Pending | Axatilimab-csfr (Niktimvo) |
| 2024-LHCC-MED-676 | Denileukin Diftitox-cxdl (Lymphir) | 12/13/24 | 1/27/25 | Pending | Denileukin Diftitox-cxdl (Lymphir) |
| 2024-LHCC-MED-677 | Palopegteriparatide (Yorvipath) | 12/13/24 | 1/27/25 | Pending | Palopegteriparatide (Yorvipath) |
| 2024-LHCC-MED-665 | Mirvetuximab soravatansine-gynx (Elahere) | 12/13/24 | 1/27/25 | Pending | Mirvetuximab soravatansine-gynx (Elahere) |
| 2024-LHCC-MED-666 | Dornase Alfa (Pulmozyme) | 12/13/24 | 1/27/25 | Pending | Dornase Alfa (Pulmozyme) |
| 2024-LHCC-MED-667 | Ofatumumab (Arzerra) | 12/13/24 | 1/27/25 | Pending | Ofatumumab (Arzerra) |
| 2024-LHCC-MED-668 | Metreleptin (Myalept) | 12/13/24 | 1/27/25 | Pending | Metreleptin (Myalept) |
| 2024-LHCC-MED-669 | Bremelanotide (Vyleesi) | 12/13/24 | 1/27/25 | Pending | Bremelanotide (Vyleesi) |
| 2024-LHCC-MED-670 | Belantamab Mafodotin-blmf (Blenrep) | 12/13/24 | 1/27/25 | Pending | Belantamab Mafodotin-blmf (Blenrep) |
| 2024-LHCC-MED-671 | Mitomycin for Pyelocalyceal Solution (Jelmyto) | 12/13/24 | 1/27/25 | Pending | Mitomycin for Pyelocalyceal Solution (Jelmyto) |
| 2024-LHCC-MED-672 | Tebentafusp-tebn (Kimmtrak) | 12/13/24 | 1/27/25 | Pending | Tebentafusp-tebn (Kimmtrak) |
| 2024-LHCC-MED-673 | Fecal Microbiota, Live-jslm (Rebyota) | 12/13/24 | 1/27/25 | Pending | Fecal Microbiota, Live-jslm (Rebyota) |
| 2024-LHCC-MED-674 | Glycopyrronium (Qbrexza) | 12/13/24 | 1/27/25 | Pending | Glycopyrronium (Qbrexza) |
| 2024-LHCC-MED-661 | Teclistamab-cqyv (Tecvayli) | 12/13/24 | 1/27/25 | Pending | Teclistamab-cqyv (Tecvayli) |
| 2024-LHCC-MED-662 | Melphalan Flufenamide (Pepaxto) | 12/13/24 | 1/27/25 | Pending | Melphalan Flufenamide (Pepaxto) |
| 2024-LHCC-MED-663 | Levoleucovorin (Fusilev, Khapzory) | 12/13/24 | 1/27/25 | Pending | Levoleucovorin (Fusilev, Khapzory) |
| 2024-LHCC-MED-664 | Hyaluronate Derivatives | 12/13/24 | 1/27/25 | Pending | Hyaluronate Derivatives |
| 2024-LHCC-MED-653 | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) | 12/13/24 | 1/27/25 | Pending | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) |
| 2024-LHCC-MED-654 | Isatuximab-irfc (Sarclisa) | 12/13/24 | 1/27/25 | Pending | Isatuximab-irfc (Sarclisa) |
| 2024-LHCC-MED-655 | Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) | 12/13/24 | 1/27/25 | Pending | Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) |
| 2024-LHCC-MED-656 | Valrubicin (Valstar) | 12/13/24 | 1/27/25 | Pending | Valrubicin (Valstar) |
| 2024-LHCC-MED-657 | Tafasitamab-cxix (Monjuvi) | 12/13/24 | 1/27/25 | Pending | Tafasitamab-cxix (Monjuvi) |
| 2024-LHCC-MED-658 | Mogamulizumab-kpkc (Poteligeo) | 12/13/24 | 1/27/25 | Pending | Mogamulizumab-kpkc (Poteligeo) |
| 2024-LHCC-MED-659 | Desmopressin Acetate (DDAVP) | 12/13/24 | 1/27/25 | Pending | Desmopressin Acetate (DDAVP) |
| 2024-LHCC-MED-660 | Irinotecan Liposome (Onivyde) | 12/13/24 | 1/27/25 | Pending | Irinotecan Liposome (Onivyde) |
| 2024-UHC-MED-226 | Maximum Dosage | 12/13/24 | 1/27/25 | Pending | Maximum Dosage |
| 2024-UHC-MED-227 | Xiaflex | 12/13/24 | 1/27/25 | Pending | Xiaflex |
| 2024-ACLA-MED-91 | Complement inhibitors | 12/13/24 | 1/27/25 | Pending | Complement inhibitors |
| 2024-ACLA-MED-92 | Veopoz | 12/13/24 | 1/27/25 | Pending | Veopoz |
| 2024-ACLA-MED-93 | Rytelo | 12/13/24 | 1/27/25 | Pending | Rytelo |
| 2024-ACLA-MED-94 | Chronic Inflammatory Demyelinating Polyneuropathy | 12/13/24 | 1/27/25 | Pending | Chronic Inflammatory Demyelinating Polyneuropathy |
| 2024-ACLA-MED-95 | Tecelra | 12/13/24 | 1/27/25 | Pending | Tecelra |
| 2024-LHCC-MED-646 | Pembrolizumab (Keytruda) | 12/5/24 | 1/19/25 | Pending | Pembrolizumab (Keytruda) |
| 2024-LHCC-MED-647 | Fam-trastuzumab deruxtecan-nxki (Enhertu) | 12/5/24 | 1/19/25 | Pending | Fam-trastuzumab deruxtecan-nxki (Enhertu) |
| 2024-LHCC-MED-648 | Lutetium Lu 177 Dotatate (Lutathera) | 12/5/24 | 1/19/25 | Pending | Lutetium Lu 177 Dotatate (Lutathera) |
| 2024-LHCC-MED-649 | Daratumumab Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex, Faspro) | 12/5/24 | 1/19/25 | Pending | Daratumumab Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex, Faspro) |
| 2024-LHCC-MED-650 | Ciltacabtagene Autoleucel (Carvykti) | 12/5/24 | 1/19/25 | Pending | Ciltacabtagene Autoleucel (Carvykti) |
| 2024-LHCC-MED-651 | Cerliponase alfa (Brineura) | 12/5/24 | 1/19/25 | Pending | Cerliponase alfa (Brineura) |
| 2024-LHCC-MED-652 | Fibrinogen concentrate (human) (Fibryga, RiaSTAP) | 12/5/24 | 1/19/25 | Pending | Fibrinogen concentrate (human) (Fibryga, RiaSTAP) |
| 2024-LHCC-MED-634 | Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars | 12/5/24 | 1/19/25 | Pending | Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars |
| 2024-LHCC-MED-635 | Nivolumab and Relatlimab (Opdualag) | 12/5/24 | 1/19/25 | Pending | Nivolumab and Relatlimab (Opdualag) |
| 2024-LHCC-MED-636 | Amivantamab-vmjw (Rybrevant) | 12/5/24 | 1/19/25 | Pending | Amivantamab-vmjw (Rybrevant) |
| 2024-LHCC-MED-637 | Brentuximab Vedotin (Adcetris) | 12/5/24 | 1/19/25 | Pending | Brentuximab Vedotin (Adcetris) |
| 2024-LHCC-MED-638 | Furosemide (Furoscix) | 12/5/24 | 1/19/25 | Pending | Furosemide (Furoscix) |
| 2024-LHCC-MED-639 | Vutrisiran (Amvuttra) | 12/5/24 | 1/19/25 | Pending | Vutrisiran (Amvuttra) |
| 2024-LHCC-MED-640 | Aflibercept (Eylea) | 12/5/24 | 1/19/25 | Pending | Aflibercept (Eylea) |
| 2024-LHCC-MED-641 | Denosumab (Xgeva) | 12/5/24 | 1/19/25 | Pending | Denosumab (Xgeva) |
| 2024-LHCC-MED-642 | Paclitaxel protein-bound (Abraxane) | 12/5/24 | 1/19/25 | Pending | Paclitaxel protein-bound (Abraxane) |
| 2024-LHCC-MED-643 | Tremelimumab-actl (Imjudo) | 12/5/24 | 1/19/25 | Pending | Tremelimumab-actl (Imjudo) |
| 2024-LHCC-MED-644 | Nadofaragene Firadenovec-vncg (Adstiladrin) | 12/5/24 | 1/19/25 | Pending | Nadofaragene Firadenovec-vncg (Adstiladrin) |
| 2024-LHCC-MED-645 | Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) | 12/5/24 | 1/19/25 | Pending | Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) |
| 2024-UHC-MED-223 | Complement inhibitors | 12/5/24 | 1/19/25 | Pending | Complement inhibitors |
| 2024-UHC-MED-224 | Review at launch new to market medications | 12/5/24 | 1/19/25 | Pending | Review at launch new to market medications |
Managed Care Pharmacy and Medical Drug Policies
In accordance with La. R.S. 46:460.51, et seq., prior to adopting, approving, amending, or implementing certain policies or procedures, LDH will publish the proposed policy or procedure for the purpose of soliciting public comments. For this purpose, a policy or procedure, as defined by the statute, shall mean a requirement governing the administration of managed care organizations specific to billing guidelines, medical management and utilization review guidelines, case management guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.
The following table contains the LDH and managed care organization pharmacy and medical drug policies that are open for public comment. Refer to the links below the table for archived postings and public comments.