Official Louisiana State Websites use .la.gov 
Secure .gov websites use HTTPS 
| Item Number | Policy/Procedure | Date Posted | Comment Period Closed | Status | Document Links |
|---|---|---|---|---|---|
| 2025-PHARM-72 | Louisiana Medicaid ICD-10 Chart May1 | 3/14/25 | 4/28/25 | Complete | Louisiana Medicaid ICD-10 Chart May1 |
| 2025-PHARM-73 | POS Oncology - Oral Prostate | 3/14/25 | 4/28/25 | Complete | POS Oncology - Oral Prostate |
| 2025-PHARM-65 | POS Androgenic Agents | 3/12/25 | 4/26/25 | Complete | POS Androgenic Agents |
| 2025-PHARM-66 | POS Estrogenic Agents and Combos | 3/12/25 | 4/26/25 | Complete | POS Estrogenic Agents and Combos |
| 2025-PHARM-67 | POS Progestational Agents | 3/12/25 | 4/26/25 | Complete | POS Progestational Agents |
| 2025-PHARM-68 | POS Progestational Agents, Other | 3/12/25 | 4/26/25 | Complete | POS Progestational Agents, Other |
| 2025-PHARM-69 | POS Prostate - BPH Treatment | 3/12/25 | 4/26/25 | Complete | POS Prostate - BPH Treatment |
| 2025-PHARM-70 | POS Spironolactone | 3/12/25 | 4/26/25 | Complete | POS Spironolactone |
| 2025-PHARM-71 | POS Testosterone, Oral/Injectable | 3/12/25 | 4/26/25 | Complete | POS Testosterone, Oral/Injectable |
| 2025-PHARM-33 | Alyftrek | 3/10/25 | 4/24/25 | Complete | Alyftrek |
| 2025-PHARM-34 | Attruby | 3/10/25 | 4/24/25 | Complete | Attruby |
| 2025-PHARM-35 | Crenessity | 3/10/25 | 4/24/25 | Complete | Crenessity |
| 2025-PHARM-36 | Davimet | 3/10/25 | 4/24/25 | Complete | Davimet |
| 2025-PHARM-37 | Depression-Antidepressants, Other | 3/10/25 | 4/24/25 | Complete | Depression-Antidepressants, Other |
| 2025-PHARM-38 | Lidotral | 3/10/25 | 4/24/25 | Complete | Lidotral |
| 2025-PHARM-39 | Louisiana Medicaid ICD-10 Chart | 3/10/25 | 4/24/25 | Complete | Louisiana Medicaid ICD-10 Chart |
| 2025-PHARM-40 | Multitam | 3/10/25 | 4/24/25 | Complete | Multitam |
| 2025-PHARM-41 | Oxervate | 3/10/25 | 4/24/25 | Complete | Oxervate |
| 2025-PHARM-42 | Pain Management - Cytokine/CAM Antagonists | 3/10/25 | 4/24/25 | Complete | Pain Management - Cytokine/CAM Antagonists |
| 2025-PHARM-43 | POS ADD-ADHD Stimulants and Related Agents | 3/10/25 | 4/24/25 | Complete | POS ADD-ADHD Stimulants and Related Agents |
| 2025-PHARM-44 | POS Alhemo | 3/10/25 | 4/24/25 | Complete | POS Alhemo |
| 2025-PHARM-45 | POS Allergy - Rhinitis Agents, Nasal | 3/10/25 | 4/24/25 | Complete | POS Allergy - Rhinitis Agents, Nasal |
| 2025-PHARM-46 | POS Antipsychotic Agents, Oral/Transdermal | 3/10/25 | 4/24/25 | Complete | POS Antipsychotic Agents, Oral/Transdermal |
| 2025-PHARM-47 | POS Asthma/COPD Bronchodilator, Beta Adrenergic Agents | 3/10/25 | 4/24/25 | Complete | POS Asthma/COPD Bronchodilator, Beta Adrenergic Agents |
| 2025-PHARM-48 | POS Attruby | 3/10/25 | 4/24/25 | Complete | POS Attruby |
| 2025-PHARM-49 | POS Butalbital-Containing Agents | 3/10/25 | 4/24/25 | Complete | POS Butalbital-Containing Agents |
| 2025-PHARM-50 | POS Davimet | 3/10/25 | 4/24/25 | Complete | POS Davimet |
| 2025-PHARM-51 | POS Dermatology - Antipsoriatics, Topical | 3/10/25 | 4/24/25 | Complete | POS Dermatology - Antipsoriatics, Topical |
| 2025-PHARM-52 | POS Diabetes - Glucagon Agents | 3/10/25 | 4/24/25 | Complete | POS Diabetes - Glucagon Agents |
| 2025-PHARM-53 | POS Diabetes - Hypoglycemics, SGLT2 Inhibitors | 3/10/25 | 4/24/25 | Complete | POS Diabetes - Hypoglycemics, SGLT2 Inhibitors |
| 2025-PHARM-54 | POS Hympavzi | 3/10/25 | 4/24/25 | Complete | POS Hympavzi |
| 2025-PHARM-55 | POS Inhaler Spacers | 3/10/25 | 4/24/25 | Complete | POS Inhaler Spacers |
| 2025-PHARM-56 | POS Lidocaine/Prilocaine | 3/10/25 | 4/24/25 | Complete | POS Lidocaine/Prilocaine |
| 2025-PHARM-57 | POS Multitam | 3/10/25 | 4/24/25 | Complete | POS Multitam |
| 2025-PHARM-58 | POS Ryvent | 3/10/25 | 4/24/25 | Complete | POS Ryvent |
| 2025-PHARM-59 | POS Smoking Cessation Products | 3/10/25 | 4/24/25 | Complete | POS Smoking Cessation Products |
| 2025-PHARM-60 | POS Sofdra | 3/10/25 | 4/24/25 | Complete | POS Sofdra |
| 2025-PHARM-61 | POS Urology - Incontinence Bladder Relaxant Preparations | 3/10/25 | 4/24/25 | Complete | POS Urology - Incontinence Bladder Relaxant Preparations |
| 2025-PHARM-62 | Sofdra | 3/10/25 | 4/24/25 | Complete | Sofdra |
| 2025-PHARM-63 | Vyalev | 3/10/25 | 4/24/25 | Complete | Vyalev |
| 2025-PHARM-64 | Yesintek | 3/10/25 | 4/24/25 | Complete | Yesintek |
| 2025-UHC-MED-233 | Maximum dosage and frequency | 2/24/25 | 4/10/25 | Complete | Maximum dosage and frequency |
| 2025-UHC-MED-234 | Denosumab-Prolia-Xgeva | 2/24/25 | 4/10/25 | Complete | Denosumab-Prolia-Xgeva |
| 2025-UHC-MED-235 | Somatostatin analogs | 2/24/25 | 4/10/25 | Complete | Somatostatin analogs |
| 2025-ACLA-MED-96 | Enzyme replacement therapy for ASMD (Xenpozyme) | 2/24/25 | 4/10/25 | Complete | Enzyme replacement therapy for ASMD (Xenpozyme) |
| 2025-ACLA-MED-97 | Pompe Disease agents | 2/24/25 | 4/10/25 | Complete | Pompe Disease agents |
| 2025-HB-MED-401 | Q423 Med PA Notice | 2/21/25 | 4/7/25 | Complete | Q423 Med PA Notice |
| 2025-HB-MED-503 | Drug and Biologic | 2/19/25 | 4/5/25 | Complete | Drug and Biologic |
| 2025-LHCC-MED-717 | Talquetamab-tgvs (Talvey) | 2/12/25 | 3/29/25 | Complete | Talquetamab-tgvs (Talvey) |
| 2025-LHCC-MED-718 | Off-Label Use | 2/12/25 | 3/29/25 | Complete | Off-Label Use |
| 2025-LHCC-MED-719 | Cemiplimab-rwlc (Libtayo) | 2/12/25 | 3/29/25 | Complete | Cemiplimab-rwlc (Libtayo) |
| 2025-LHCC-MED-720 | Carfilzomib (Kyprolis) | 2/12/25 | 3/29/25 | Complete | Carfilzomib (Kyprolis) |
| 2025-LHCC-MED-721 | Cetuximab (Erbitux) | 2/12/25 | 3/29/25 | Complete | Cetuximab (Erbitux) |
| 2025-LHCC-MED-722 | Brexucabtagene Autoleucel (Tecartus) | 2/12/25 | 3/29/25 | Complete | Brexucabtagene Autoleucel (Tecartus) |
| 2025-LHCC-MED-723 | Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase | 2/12/25 | 3/29/25 | Complete | Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase |
| 2025-LHCC-MED-724 | Azacitidine (Vidaza) | 2/12/25 | 3/29/25 | Complete | Azacitidine (Vidaza) |
| 2025-LHCC-MED-725 | Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) | 2/12/25 | 3/29/25 | Complete | Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) |
| 2025-LHCC-MED-726 | Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) | 2/12/25 | 3/29/25 | Complete | Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) |
| 2025-LHCC-MED-727 | Eplontersen (Wainua) | 2/12/25 | 3/29/25 | Complete | Eplontersen (Wainua) |
| 2025-LHCC-MED-728 | Atezolizumab (Tecentriq) | 2/12/25 | 3/29/25 | Complete | Atezolizumab (Tecentriq) |
| 2025-LHCC-MED-729 | Rozanolixizumab-noli (Rystiggo) | 2/12/25 | 3/29/25 | Complete | Rozanolixizumab-noli (Rystiggo) |
| 2025-LHCC-MED-710 | ADAMTS13, recombinant-krhn (Adzynma) | 2/10/25 | 3/27/25 | Complete | ADAMTS13, recombinant-krhn (Adzynma) |
| 2025-LHCC-MED-711 | Pemetrexed (Alimta, Pemfexy) | 2/10/25 | 3/27/25 | Complete | Pemetrexed (Alimta, Pemfexy) |
| 2025-LHCC-MED-712 | Melphalan (Hepzato) | 2/10/25 | 3/27/25 | Complete | Melphalan (Hepzato) |
| 2025-LHCC-MED-713 | Elranatamab-bcmm (Elrexfio) | 2/10/25 | 3/27/25 | Complete | Elranatamab-bcmm (Elrexfio) |
| 2025-LHCC-MED-714 | Vadadustat (Vafseo) | 2/10/25 | 3/27/25 | Complete | Vadadustat (Vafseo) |
| 2025-LHCC-MED-715 | Nivolumab (Opdivo) | 2/10/25 | 3/27/25 | Complete | Nivolumab (Opdivo) |
| 2025-LHCC-MED-716 | Efgartigimod Alfa-fcab (Vyvgart) | 2/10/25 | 3/27/25 | Complete | Efgartigimod Alfa-fcab (Vyvgart) |
| 2025-LHCC-MED-704 | Asfotase Alfa (Strensiq) | 1/30/25 | 3/16/25 | Complete | Asfotase Alfa (Strensiq) |
| 2025-LHCC-MED-705 | Moxetumomab pasudotox-tdfk (Lumoxiti) | 1/30/25 | 3/16/25 | Complete | Moxetumomab pasudotox-tdfk (Lumoxiti) |
| 2025-LHCC-MED-706 | No Coverage Criteria | 1/30/25 | 3/16/25 | Complete | No Coverage Criteria |
| 2025-LHCC-MED-707 | Antithrombin III (ATryn, Thrombate III) | 1/30/25 | 3/16/25 | Complete | Antithrombin III (ATryn, Thrombate III) |
| 2025-LHCC-MED-708 | DaxibotulinumtoxinA-lanm (Daxxify) | 1/30/25 | 3/16/25 | Complete | DaxibotulinumtoxinA-lanm (Daxxify) |
| 2025-LHCC-MED-709 | Motixafortide (Aphexda) | 1/30/25 | 3/16/25 | Complete | Motixafortide (Aphexda) |
| 2025-HB-MED-494 | Brineura (cerliponase alfa) | 1/29/25 | 3/15/25 | Complete | Brineura (cerliponase alfa) |
| 2025-HB-MED-495 | Veopoz (pozelimab-bbfg) | 1/29/25 | 3/15/25 | Complete | Veopoz (pozelimab-bbfg) |
| 2025-HB-MED-496 | Vascular Endothelial Growth Factor (VEGF) Inhibitors | 1/29/25 | 3/15/25 | Complete | Vascular Endothelial Growth Factor (VEGF) Inhibitors |
| 2025-HB-MED-497 | Erbitux (cetuximab) | 1/29/25 | 3/15/25 | Complete | Erbitux (cetuximab) |
| 2025-HB-MED-498 | Rybrevant (amivantamab-ymjw) | 1/29/25 | 3/15/25 | Complete | Rybrevant (amivantamab-ymjw) |
| 2025-HB-MED-499 | Imfinzi (durvalumab) | 1/29/25 | 3/15/25 | Complete | Imfinzi (durvalumab) |
| 2025-LHCC-MED-695 | Obinutuzumab (Gazyva) | 1/24/25 | 3/10/25 | Complete | Obinutuzumab (Gazyva) |
| 2025-LHCC-MED-696 | Belinostat (Beleodaq) | 1/24/25 | 3/10/25 | Complete | Belinostat (Beleodaq) |
| 2025-LHCC-MED-697 | Pralatrexate (Folotyn) | 1/24/25 | 3/10/25 | Complete | Pralatrexate (Folotyn) |
| 2025-LHCC-MED-698 | Romidepsin (Istodax) | 1/24/25 | 3/10/25 | Complete | Romidepsin (Istodax) |
| 2025-LHCC-MED-699 | Panitumumab (Vectibix) | 1/24/25 | 3/10/25 | Complete | Panitumumab (Vectibix) |
| 2025-LHCC-MED-700 | Temsirolimus (Torisel) | 1/24/25 | 3/10/25 | Complete | Temsirolimus (Torisel) |
| 2025-LHCC-MED-701 | Pegaspargase (Oncaspar), Calaspargase Pegol-mknl | 1/24/25 | 3/10/25 | Complete | Pegaspargase (Oncaspar), Calaspargase Pegol-mknl |
| 2025-LHCC-MED-702 | Gemtuzumab Ozogamicin (Mylotarg) | 1/24/25 | 3/10/25 | Complete | Gemtuzumab Ozogamicin (Mylotarg) |
| 2025-LHCC-MED-703 | Antithymocyte Globulin (Atgam, Thymoglobulin) | 1/24/25 | 3/10/25 | Complete | Antithymocyte Globulin (Atgam, Thymoglobulin) |
| 2024-LHCC-MED-683 | Degarelix Acetate (Firmagon) | 1/9/25 | 2/23/25 | Complete | Degarelix Acetate (Firmagon) |
| 2024-LHCC-MED-684 | Belatacept (Nulojix) | 1/9/25 | 2/23/25 | Complete | Belatacept (Nulojix) |
| 2024-LHCC-MED-685 | Immunization coverage | 1/9/25 | 2/23/25 | Complete | Immunization coverage |
| 2024-LHCC-MED-686 | Eribulin Mesylate (Halaven) | 1/9/25 | 2/23/25 | Complete | Eribulin Mesylate (Halaven) |
| 2024-LHCC-MED-687 | Necitumumab (Portrazza) | 1/9/25 | 2/23/25 | Complete | Necitumumab (Portrazza) |
| 2024-LHCC-MED-688 | Ziv-aflibercept (Zaltrap) | 1/9/25 | 2/23/25 | Complete | Ziv-aflibercept (Zaltrap) |
| 2024-LHCC-MED-689 | Daunorubicin/Cytarabine (Vyxeos) | 1/9/25 | 2/23/25 | Complete | Daunorubicin/Cytarabine (Vyxeos) |
| 2024-LHCC-MED-690 | Leucovorin Injection | 1/9/25 | 2/23/25 | Complete | Leucovorin Injection |
| 2024-LHCC-MED-691 | Pegunigalsidase alfa-iwxj (Elfabrio) | 1/9/25 | 2/23/25 | Complete | Pegunigalsidase alfa-iwxj (Elfabrio) |
| 2024-LHCC-MED-692 | Plasminogen, Human-tvmh (Ryplazim) | 1/9/25 | 2/23/25 | Complete | Plasminogen, Human-tvmh (Ryplazim) |
| 2024-LHCC-MED-693 | Tofersen (Qalsody) | 1/9/25 | 2/23/25 | Complete | Tofersen (Qalsody) |
| 2024-LHCC-MED-694 | Velmanase Alfa-tycv (Lamzede) | 1/9/25 | 2/23/25 | Complete | Velmanase Alfa-tycv (Lamzede) |
| 2024-LHCC-MED-678 | Pasireotide (Signifor, Signifor LAR) | 1/9/25 | 2/23/25 | Complete | Pasireotide (Signifor, Signifor LAR) |
| 2024-LHCC-MED-679 | Copanlisib (Aliqopa) | 1/9/25 | 2/23/25 | Complete | Copanlisib (Aliqopa) |
| 2024-LHCC-MED-680 | Pegvisomant (Somavert) | 1/9/25 | 2/23/25 | Complete | Pegvisomant (Somavert) |
| 2024-LHCC-MED-681 | Lanreotide (Somatuline Depot) | 1/9/25 | 2/23/25 | Complete | Lanreotide (Somatuline Depot) |
| 2024-LHCC-MED-682 | Pegcetacoplan (Empaveli, Syfovre) | 1/9/25 | 2/23/25 | Complete | Pegcetacoplan (Empaveli, Syfovre) |
| 2025-UHC-MED-228 | Oncology medication clinical coverage | 1/8/25 | 2/22/25 | Complete | Oncology medication clinical coverage |
| 2025-UHC-MED-229 | Provider administered drugs site of care | 1/8/25 | 2/22/25 | Complete | Provider administered drugs site of care |
| 2025-UHC-MED-230 | Botulinum toxins a and b | 1/8/25 | 2/22/25 | Complete | Botulinum toxins a and b |
| 2025-UHC-MED-231 | Iron replacement therapy | 1/8/25 | 2/22/25 | Complete | Iron replacement therapy |
| 2025-UHC-MED-232 | Tepezza | 1/8/25 | 2/22/25 | Complete | Tepezza |
| 2025-HB-MED-490 | Tecelra | 1/8/25 | 2/22/25 | Complete | Tecelra |
| 2025-HB-MED-491 | Niktimvo | 1/8/25 | 2/22/25 | Complete | Niktimvo |
| 2025-HB-MED-493 | Lymphir | 1/8/25 | 2/22/25 | Complete | Lymphir |
| 2025-LHCC-MED-632 | Sotatercept (Winrevair) | 1/8/25 | 2/22/25 | Complete | Sotatercept (Winrevair) |
| 2025-PHARM-1 | Aqneursa | 1/8/25 | 2/22/25 | Complete | Aqneursa |
| 2025-PHARM-2 | Asthma, Immunomodulators | 1/8/25 | 2/22/25 | Complete | Asthma, Immunomodulators |
| 2025-PHARM-3 | Colony Stimulating Factors | 1/8/25 | 2/22/25 | Complete | Colony Stimulating Factors |
| 2025-PHARM-4 | Dermatology - Atopic Dermatitis, Immunomodulators | 1/8/25 | 2/22/25 | Complete | Dermatology - Atopic Dermatitis, Immunomodulators |
| 2025-PHARM-5 | Duvyzat | 1/8/25 | 2/22/25 | Complete | Duvyzat |
| 2025-PHARM-6 | Ebglyss | 1/8/25 | 2/22/25 | Complete | Ebglyss |
| 2025-PHARM-7 | Lodoco | 1/8/25 | 2/22/25 | Complete | Lodoco |
| 2025-PHARM-8 | Louisiana Medicaid ICD-10 Chart | 1/8/25 | 2/22/25 | Complete | Louisiana Medicaid ICD-10 Chart |
| 2025-PHARM-9 | Max Dose Override Buprenorphine | 1/8/25 | 2/22/25 | Complete | Max Dose Override Buprenorphine |
| 2025-PHARM-10 | Miplyffa | 1/8/25 | 2/22/25 | Complete | Miplyffa |
| 2025-PHARM-11 | Narcotics Quantity Limit and MME Override | 1/8/25 | 2/22/25 | Complete | Narcotics Quantity Limit and MME Override |
| 2025-PHARM-12 | Nemluvio | 1/8/25 | 2/22/25 | Complete | Nemluvio |
| 2025-PHARM-13 | Ocrevus Zunovo | 1/8/25 | 2/22/25 | Complete | Ocrevus Zunovo |
| 2025-PHARM-14 | Pain Management, Cytokine and CAM Antagonists | 1/8/25 | 2/22/25 | Complete | Pain Management, Cytokine and CAM Antagonists |
| 2025-PHARM-15 | Pain Management, LA Narcotic Analgesics | 1/8/25 | 2/22/25 | Complete | Pain Management, LA Narcotic Analgesics |
| 2025-PHARM-16 | Pain Management, SA Narcotic Analgesics | 1/8/25 | 2/22/25 | Complete | Pain Management, SA Narcotic Analgesics |
| 2025-PHARM-17 | POS ADD-ADHD Stimulants and Related Agents | 1/8/25 | 2/22/25 | Complete | POS ADD-ADHD Stimulants and Related Agents |
| 2025-PHARM-18 | POS Anticonvulsants | 1/8/25 | 2/22/25 | Complete | POS Anticonvulsants |
| 2025-PHARM-19 | POS Asthma - COPD, Glucocorticoids Inhalation | 1/8/25 | 2/22/25 | Complete | POS Asthma - COPD, Glucocorticoids Inhalation |
| 2025-PHARM-20 | POS Cobenfy | 1/8/25 | 2/22/25 | Complete | POS Cobenfy |
| 2025-PHARM-21 | POS Dermatology - Antibiotics, Topical | 1/8/25 | 2/22/25 | Complete | POS Dermatology - Antibiotics, Topical |
| 2025-PHARM-22 | POS Dermatology - Atopic Dermatitis, Immunomodulators | 1/8/25 | 2/22/25 | Complete | POS Dermatology - Atopic Dermatitis, Immunomodulators |
| 2025-PHARM-23 | POS Diabetes - Hypoglycemics, Incretin Mimetics/Enhancers | 1/8/25 | 2/22/25 | Complete | POS Diabetes - Hypoglycemics, Incretin Mimetics/Enhancers |
| 2025-PHARM-24 | POS Diabetes - Hypoglycemics, Insulins and Related Agents | 1/8/25 | 2/22/25 | Complete | POS Diabetes - Hypoglycemics, Insulins and Related Agents |
| 2025-PHARM-25 | POS Erzofri | 1/8/25 | 2/22/25 | Complete | POS Erzofri |
| 2025-PHARM-26 | POS GI Motility Chronic | 1/8/25 | 2/22/25 | Complete | POS GI Motility Chronic |
| 2025-PHARM-27 | POS Lodoco | 1/8/25 | 2/22/25 | Complete | POS Lodoco |
| 2025-PHARM-28 | POS Neffy | 1/8/25 | 2/22/25 | Complete | POS Neffy |
| 2025-PHARM-29 | POS Ophthalmic Disorders, Anti-Inflammatory Immunomodulators | 1/8/25 | 2/22/25 | Complete | POS Ophthalmic Disorders, Anti-Inflammatory Immunomodulators |
| 2025-PHARM-30 | POS Opiate Dependence Agents | 1/8/25 | 2/22/25 | Complete | POS Opiate Dependence Agents |
| 2025-PHARM-31 | POS Pain Management - Antimigraine Agents, CGRP Antagonists | 1/8/25 | 2/22/25 | Complete | POS Pain Management - Antimigraine Agents, CGRP Antagonists |
| 2025-PHARM-32 | Vyondys | 1/8/25 | 2/22/25 | Complete | Vyondys |
Medicaid Managed Care Policies & Procedures Archive - Pharmacy (2025)
"Policy or procedure" 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.
Below are items previously posted for public comment:
Related Info