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. To provide feedback, please complete this form. Refer to the links below the table for archived postings and public comments.

Item Number	Policy/Procedure Date Posted Comment Period Closed Status	Date Posted	Comment Period Closed Status	Status	Document Links
2026-PHARM-38	Aqvesme	4/30/26	6/14/26	Pending	Aqvesme
2026-PHARM-39	Blujepa	4/30/26	6/14/26	Pending	Blujepa
2026-PHARM-40	Dermatology - Atopic Dermatitis, Immunomodulators	4/30/26	6/14/26	Pending	Dermatology - Atopic Dermatitis, Immunomodulators
2026-PHARM-41	Exdensur	4/30/26	6/14/26	Pending	Exdensur
2026-PHARM-42	Forzinity	4/30/26	6/14/26	Pending	Forzinity
2026-PHARM-43	Heart Disease - Hyperlipidemia, Lipotropics Other	4/30/26	6/14/26	Pending	Heart Disease - Hyperlipidemia, Lipotropics Other
2026-PHARM-44	Hereditary Angioedema	4/30/26	6/14/26	Pending	Hereditary Angioedema
2026-PHARM-45	Itvisma	4/30/26	6/14/26	Pending	Itvisma
2026-PHARM-46	Louisiana Medicaid ICD-10 Chart	4/30/26	6/14/26	Pending	Louisiana Medicaid ICD-10 Chart
2026-PHARM-47	Lynkuet	4/30/26	6/14/26	Pending	Lynkuet
2026-PHARM-48	Multivitamins	4/30/26	6/14/26	Pending	Multivitamins
2026-PHARM-49	Myqorzo	4/30/26	6/14/26	Pending	Myqorzo
2026-PHARM-50	Orlynvah	4/30/26	6/14/26	Pending	Orlynvah
2026-PHARM-51	Pain Management - Cytokine/CAM Antagonists	4/30/26	6/14/26	Pending	Pain Management - Cytokine/CAM Antagonists
2026-PHARM-52	Pain Management - Non-Steroidal AntiInflammatory Agents	4/30/26	6/14/26	Pending	Pain Management - Non-Steroidal AntiInflammatory Agents
2026-PHARM-53	Pain Management - Skeletal Muscle Relaxants	4/30/26	6/14/26	Pending	Pain Management - Skeletal Muscle Relaxants
2026-PHARM-54	Papzimeos	4/30/26	6/14/26	Pending	Papzimeos
2026-PHARM-55	Pediatric Multivitamins with Fluoride	4/30/26	6/14/26	Pending	Pediatric Multivitamins with Fluoride
2026-PHARM-56	POS ADD-ADHD Stimulants and Related Agents	4/30/26	6/14/26	Pending	POS ADD-ADHD Stimulants and Related Agents
2026-PHARM-57	POS Allergy - Antihistamines, Minimally Sedating	4/30/26	6/14/26	Pending	POS Allergy - Antihistamines, Minimally Sedating
2026-PHARM-58	POS Antipsychotic Agents, Oral/Transdermal	4/30/26	6/14/26	Pending	POS Antipsychotic Agents, Oral/Transdermal
2026-PHARM-59	POS Aqvesme	4/30/26	6/14/26	Pending	POS Aqvesme
2026-PHARM-60	POS Blujepa	4/30/26	6/14/26	Pending	POS Blujepa
2026-PHARM-61	POS Dermatology - Atopic Dermatitis, Immunomodulators	4/30/26	6/14/26	Pending	POS Dermatology - Atopic Dermatitis, Immunomodulators
2026-PHARM-62	POS Exdensur	4/30/26	6/14/26	Pending	POS Exdensur
2026-PHARM-63	POS Exxua	4/30/26	6/14/26	Pending	POS Exxua
2026-PHARM-64	POS Lynkuet	4/30/26	6/14/26	Pending	POS Lynkuet
2026-PHARM-65	POS Myqorzo	4/30/26	6/14/26	Pending	POS Myqorzo
2026-PHARM-66	POS Orlynvah	4/30/26	6/14/26	Pending	POS Orlynvah
2026-PHARM-67	POS Pain Management - Non-Steroidal AntiInflammatory Agents	4/30/26	6/14/26	Pending	POS Pain Management - Non-Steroidal AntiInflammatory Agents
2026-PHARM-68	POS Pain Management - Skeletal Muscle Relaxants	4/30/26	6/14/26	Pending	POS Pain Management - Skeletal Muscle Relaxants
2026-PHARM-69	POS Voyxact	4/30/26	6/14/26	Pending	POS Voyxact
2026-PHARM-70	POS Zepbound	4/30/26	6/14/26	Pending	POS Zepbound
2026-PHARM-71	Redemplo	4/30/26	6/14/26	Pending	Redemplo
2026-PHARM-72	Sedative/Hypnotics	4/30/26	6/14/26	Pending	Sedative/Hypnotics
2026-PHARM-73	Starjemza	4/30/26	6/14/26	Pending	Starjemza
2026-PHARM-74	Yartemlea	4/30/26	6/14/26	Pending	Yartemlea
2026-PHARM-75	Zycubo	4/30/26	6/14/26	Pending	Zycubo
2026-LHCC-MED-974	Epoprostenol (Flolan, Veletri)	4/8/26	5/23/26	Pending	Epoprostenol (Flolan, Veletri)
2026-LHCC-MED-975	Enfortumab Vedotin-ejfv (Padcev)	4/8/26	5/23/26	Pending	Enfortumab Vedotin-ejfv (Padcev)
2026-LHCC-MED-976	Verteporfin (Visudyne)	4/8/26	5/23/26	Pending	Verteporfin (Visudyne)
2026-LHCC-MED-977	Trabectedin (Yondelis)	4/8/26	5/23/26	Pending	Trabectedin (Yondelis)
2026-LHCC-MED-978	Avelumab (Bavencio)	4/8/26	5/23/26	Pending	Avelumab (Bavencio)
2026-LHCC-MED-979	Tisagenlecleucel (Kymriah)	4/8/26	5/23/26	Pending	Tisagenlecleucel (Kymriah)
2026-LHCC-MED-980	Voretigene Neparvovec-rzyl (Luxturna)	4/8/26	5/23/26	Pending	Voretigene Neparvovec-rzyl (Luxturna)
2026-LHCC-MED-981	Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa)	4/8/26	5/23/26	Pending	Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia, Mycapssa)
2026-LHCC-MED-982	Toripalimab-tpzi (Loqtorzi)	4/8/26	5/23/26	Pending	Toripalimab-tpzi (Loqtorzi)
2026-LHCC-MED-983	Eladocagene Exuparvovec-tneq (Kebilidi)	4/8/26	5/23/26	Pending	Eladocagene Exuparvovec-tneq (Kebilidi)
2026-LHCC-MED-984	Siltuximab (Sylvant)	4/8/26	5/23/26	Pending	Siltuximab (Sylvant)
2026-LHCC-MED-985	Eteclacalcetide (Parsabiv)	4/8/26	5/23/26	Pending	Eteclacalcetide (Parsabiv)
2026-LHCC-MED-986	Paricalcitol Injection (Zemplar)	4/8/26	5/23/26	Pending	Paricalcitol Injection (Zemplar)
2026-LHCC-MED-987	Teclistamab-cqyv (Tecvayli)	4/8/26	5/23/26	Pending	Teclistamab-cqyv (Tecvayli)
2026-LHCC-MED-988	Linvoseltamab-gcpt (Lynozyfic)	4/8/26	5/23/26	Pending	Linvoseltamab-gcpt (Lynozyfic)
2026-LHCC-MED-989	Burosumab-twza (Crysvita)	4/8/26	5/23/26	Pending	Burosumab-twza (Crysvita)
2026-LHCC-MED-990	Ferric Derisomaltose (Monoferric)	4/8/26	5/23/26	Pending	Ferric Derisomaltose (Monoferric)
2026-LHCC-MED-991	Pertuzumab (Perjeta), Pertuzumab-dpzb (Poherdy)	4/8/26	5/23/26	Pending	Pertuzumab (Perjeta), Pertuzumab-dpzb (Poherdy)
2026-LHCC-MED-992	Datopotamab deruxtecan-dlnk (Datroway)	4/8/26	5/23/26	Pending	Datopotamab deruxtecan-dlnk (Datroway)
2026-LHCC-MED-963	Sodium thiosulfate (Pedmark)	4/8/26	5/23/26	Pending	Sodium thiosulfate (Pedmark)
2026-LHCC-MED-964	Alglucosidase Alfa (Lumizyme)	4/8/26	5/23/26	Pending	Alglucosidase Alfa (Lumizyme)
2026-LHCC-MED-965	Erwinia Asparaginase (Erwinaze, Rylaze)	4/8/26	5/23/26	Pending	Erwinia Asparaginase (Erwinaze, Rylaze)
2026-LHCC-MED-966	Protein C Concentrate, Human (Ceprotin)	4/8/26	5/23/26	Pending	Protein C Concentrate, Human (Ceprotin)
2026-LHCC-MED-967	Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda)	4/8/26	5/23/26	Pending	Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda)
2026-LHCC-MED-968	Mirvetuximab soravatansine-gynx (Elahere)	4/8/26	5/23/26	Pending	Mirvetuximab soravatansine-gynx (Elahere)
2026-LHCC-MED-969	Retifanlimab-dlwr (Zynyz)	4/8/26	5/23/26	Pending	Retifanlimab-dlwr (Zynyz)
2026-LHCC-MED-970	Zanidatamab-hrii (Ziihera)	4/8/26	5/23/26	Pending	Zanidatamab-hrii (Ziihera)
2026-LHCC-MED-971	Zolbetuximab-clzb (Vyloy)	4/8/26	5/23/26	Pending	Zolbetuximab-clzb (Vyloy)
2026-LHCC-MED-972	Antithrombin III (ATryn, Thrombate III)	4/8/26	5/23/26	Pending	Antithrombin III (ATryn, Thrombate III)
2026-LHCC-MED-973	Daratumumab Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex, Faspro)	4/8/26	5/23/26	Pending	Daratumumab Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex, Faspro)
2026-LHCC-MED-948	Afamelanotide (Scenesse)	3/18/26	5/2/26	Pending	Afamelanotide (Scenesse)
2026-LHCC-MED-949	Brolucizumab-dbll (Beovu)	3/18/26	5/2/26	Pending	Brolucizumab-dbll (Beovu)
2026-LHCC-MED-950	Avalglucosidase Alfa-ngpt (Nexviazyme)	3/18/26	5/2/26	Pending	Avalglucosidase Alfa-ngpt (Nexviazyme)
2026-LHCC-MED-951	Margetuximab-cmkb (Margenza)	3/18/26	5/2/26	Pending	Margetuximab-cmkb (Margenza)
2026-LHCC-MED-952	Naxitamab-gqgk (Danyelza)	3/18/26	5/2/26	Pending	Naxitamab-gqgk (Danyelza)
2026-LHCC-MED-953	Ropeginterferon Alfa-2b-njft (BESREMi)	3/18/26	5/2/26	Pending	Ropeginterferon Alfa-2b-njft (BESREMi)
2026-LHCC-MED-954	Sirolimus Protein-Bound Particles (Fyarro)	3/18/26	5/2/26	Pending	Sirolimus Protein-Bound Particles (Fyarro)
2026-LHCC-MED-955	Interferon Gamma-1b (Actimmune)	3/18/26	5/2/26	Pending	Interferon Gamma-1b (Actimmune)
2026-LHCC-MED-956	Faricimab-svoa (Vabysmo)	3/18/26	5/2/26	Pending	Faricimab-svoa (Vabysmo)
2026-LHCC-MED-957	Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)	3/18/26	5/2/26	Pending	Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)
2026-LHCC-MED-958	Zilucoplan (Zilbrysq)	3/18/26	5/2/26	Pending	Zilucoplan (Zilbrysq)
2026-LHCC-MED-959	Ferric Carboxymaltose (Injectafer)	3/18/26	5/2/26	Pending	Ferric Carboxymaltose (Injectafer)
2026-LHCC-MED-960	Bortezomib (Velcade)	3/18/26	5/2/26	Pending	Bortezomib (Velcade)
2026-LHCC-MED-961	Cosibelimab-Ipdl (Unloxcyt)	3/18/26	5/2/26	Pending	Cosibelimab-Ipdl (Unloxcyt)
2026-LHCC-MED-962	Zenocutuzumab-zbco (Bizengri)	3/18/26	5/2/26	Pending	Zenocutuzumab-zbco (Bizengri)
2026-LHCC-MED-944	Lisocabtagene Maraleucel (Breyanzi)	3/18/26	5/2/26	Pending	Lisocabtagene Maraleucel (Breyanzi)
2026-LHCC-MED-945	Lifileucel (Amtagvi)	3/18/26	5/2/26	Pending	Lifileucel (Amtagvi)
2026-LHCC-MED-946	Obecabtagene autoleucel (Aucatzyl)	3/18/26	5/2/26	Pending	Obecabtagene autoleucel (Aucatzyl)
2026-LHCC-MED-947	Axicabtagene ciloleucel (Yescarta)	3/18/26	5/2/26	Pending	Axicabtagene ciloleucel (Yescarta)
2026-LHCC-MED-939	Aflibercept (Eylea, Eylea HD) and Biosimilars)	3/17/26	5/1/26	Pending	Aflibercept (Eylea, Eylea HD) and Biosimilars)
2026-LHCC-MED-940	Mosunetuzumab-axgb (Lunsumio)	3/17/26	5/1/26	Pending	Mosunetuzumab-axgb (Lunsumio)
2026-LHCC-MED-941	Hemin (Panhematin)	3/17/26	5/1/26	Pending	Hemin (Panhematin)
2026-LHCC-MED-942	Emapalumab-lzsg (Gamifant)	3/17/26	5/1/26	Pending	Emapalumab-lzsg (Gamifant)
2026-LHCC-MED-943	Pembrolizumab, Pembrolizumab-Berahyaluronidase Alfa-pmph (Keytruda, Keytruda Qlex)	3/17/26	5/1/26	Pending	Pembrolizumab, Pembrolizumab-Berahyaluronidase Alfa-pmph (Keytruda, Keytruda Qlex)
2026-HB-MED-666	Aliqopa (copanlisib)	3/12/26	4/26/26	Pending	Aliqopa (copanlisib)
2026-HB-MED-667	Tecartus (brexucabtagene autoleucel)	3/12/26	4/26/26	Pending	Tecartus (brexucabtagene autoleucel)
2026-HB-MED-668	Besremi (ropeginterferon alfa-2b-njft)	3/12/26	4/26/26	Pending	Besremi (ropeginterferon alfa-2b-njft)
2026-HB-MED-670	Tecvayli (teclistamab-cqyv)	3/12/26	4/26/26	Pending	Tecvayli (teclistamab-cqyv)
2026-HB-MED-671	Imjudo (tremelimumab-actl)	3/12/26	4/26/26	Pending	Imjudo (tremelimumab-actl)
2026-HB-MED-672	Talvey (talquetamab-tgvs)	3/12/26	4/26/26	Pending	Talvey (talquetamab-tgvs)
2026-HB-MED-673	Loqtorzi (toripalimab-tpzi)	3/12/26	4/26/26	Pending	Loqtorzi (toripalimab-tpzi)
2026-HB-MED-674	Aucatzyl (obecabtagene autoleucel)	3/12/26	4/26/26	Pending	Aucatzyl (obecabtagene autoleucel)
2026-HB-MED-675	Ziihera (zanidatamab-hrii)	3/12/26	4/26/26	Pending	Ziihera (zanidatamab-hrii)
2026-HB-MED-656	Forzinity (elamipretide)	3/12/26	4/26/26	Pending	Forzinity (elamipretide)
2026-HB-MED-657	Ethyol (amifostine)	3/12/26	4/26/26	Pending	Ethyol (amifostine)
2026-HB-MED-658	Fyarro (sirolimus albumin bound)	3/12/26	4/26/26	Pending	Fyarro (sirolimus albumin bound)
2026-HB-MED-659	Elrexfio (elranatamab-bcmm)	3/12/26	4/26/26	Pending	Elrexfio (elranatamab-bcmm)
2026-HB-MED-660	Radicava (edaravone)	3/12/26	4/26/26	Pending	Radicava (edaravone)
2026-HB-MED-661	Vascular Endothelial Growth Factor (VEGF) Inhibitors	3/12/26	4/26/26	Pending	Vascular Endothelial Growth Factor (VEGF) Inhibitors
2026-HB-MED-662	Alpha-1 Proteinase Inhibitor Therapy	3/12/26	4/26/26	Pending	Alpha-1 Proteinase Inhibitor Therapy
2026-HB-MED-663	Bendamustine agents	3/12/26	4/26/26	Pending	Bendamustine agents
2026-HB-MED-664	Kyprolis (carfilzomib)	3/12/26	4/26/26	Pending	Kyprolis (carfilzomib)
2026-HB-MED-665	Keytruda (pembrolizumab)	3/12/26	4/26/26	Pending	Keytruda (pembrolizumab)
2026-LHCC-MED-927	Ibandronate Injection (Boniva)	3/5/26	4/19/26	Pending	Ibandronate Injection (Boniva)
2026-LHCC-MED-928	Panitumumab (Vectibix)	3/5/26	4/19/26	Pending	Panitumumab (Vectibix)
2026-LHCC-MED-929	Durvalumab (Imfinzi)	3/5/26	4/19/26	Pending	Durvalumab (Imfinzi)
2026-LHCC-MED-930	Tislelizumab-jsgr (Tevimbra)	3/5/26	4/19/26	Pending	Tislelizumab-jsgr (Tevimbra)
2026-LHCC-MED-931	Cetuximab (Erbitux)	3/5/26	4/19/26	Pending	Cetuximab (Erbitux)
2026-LHCC-MED-932	Inotersen (Tegsedi)	3/5/26	4/19/26	Pending	Inotersen (Tegsedi)
2026-LHCC-MED-933	Agalsidase Beta (Fabrazyme)	3/5/26	4/19/26	Pending	Agalsidase Beta (Fabrazyme)
2026-LHCC-MED-934	Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev)	3/5/26	4/19/26	Pending	Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev)
2026-LHCC-MED-935	Epcoritamab-bysp (Epkinly)	3/5/26	4/19/26	Pending	Epcoritamab-bysp (Epkinly)
2026-LHCC-MED-936	Ferumoxytol (Feraheme)	3/5/26	4/19/26	Pending	Ferumoxytol (Feraheme)
2026-LHCC-MED-937	Off-Label Use	3/5/26	4/19/26	Pending	Off-Label Use
2026-LHCC-MED-938	No Coverage Criteria	3/5/26	4/19/26	Pending	No Coverage Criteria
2026-LHCC-MED-924	Hyaluronate Derivatives	3/4/26	4/18/26	Pending	Hyaluronate Derivatives
2026-LHCC-MED-925	Mitomycin Instillation Solution (Jelmyto, Zusduri)	3/4/26	4/18/26	Pending	Mitomycin Instillation Solution (Jelmyto, Zusduri)
2026-LHCC-MED-926	Nipocalimab-aahu (Imaavy)	3/4/26	4/18/26	Pending	Nipocalimab-aahu (Imaavy)
2026-LHCC-MED-918	Elotuzumab (Empliciti)	3/4/26	4/18/26	Pending	Elotuzumab (Empliciti)
2026-LHCC-MED-919	Tarlatamab-dlle (Imdelltra)	3/4/26	4/18/26	Pending	Tarlatamab-dlle (Imdelltra)
2026-LHCC-MED-920	Parathyroid hormone (Natpara)	3/4/26	4/18/26	Pending	Parathyroid hormone (Natpara)
2026-LHCC-MED-921	Trofinetide (Daybue, Daybue Stix)	3/4/26	4/18/26	Pending	Trofinetide (Daybue, Daybue Stix)
2026-LHCC-MED-922	Idecabtagene Vicleucel (Abecma)	3/4/26	4/18/26	Pending	Idecabtagene Vicleucel (Abecma)
2026-LHCC-MED-923	Afamitresgene Autoleucel (Tecelra)	3/4/26	4/18/26	Pending	Afamitresgene Autoleucel (Tecelra)