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 Document Links
2024-LHCC-MED-558 Ramucirumab (Cyramza) 6/6/24 7/21/24 Pending Ramucirumab (Cyramza)
2024-LHCC-MED-559 Nivolumab (Opdivo) 6/6/24 7/21/24 Pending Nivolumab (Opdivo)
2024-LHCC-MED-560 Deferoxamine (Desferal) 6/6/24 7/21/24 Pending Deferoxamine (Desferal)
2024-LHCC-MED-561 Trastuzumab Biosimilars Trastuzumab-Hyaluronidase 6/6/24 7/21/24 Pending Trastuzumab Biosimilars Trastuzumab-Hyaluronidase
2024-LHCC-MED-562 Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela) 6/6/24 7/21/24 Pending Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela)
2024-LHCC-MED-563 Durvalumab (Imfinzi) 6/6/24 7/21/24 Pending Durvalumab (Imfinzi)
2024-LHCC-MED-564 Cemiplimab-rwlc (Libtayo) 6/6/24 7/21/24 Pending Cemiplimab-rwlc (Libtayo)
2024-LHCC-MED-565 Enfortumab Vedotin-ejfv (Padcev) 6/6/24 7/21/24 Pending Enfortumab Vedotin-ejfv (Padcev)
2024-LHCC-MED-566 Faricimab (Vabysmo) 6/6/24 7/21/24 Pending Faricimab (Vabysmo)
2024-LHCC-MED-567 Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev) 6/6/24 7/21/24 Pending Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)
2024-LHCC-MED-568 Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) 6/6/24 7/21/24 Pending Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira)
2024-LHCC-MED-569 Ravulizumab-cwvz (Ultomiris) 6/6/24 7/21/24 Pending Ravulizumab-cwvz (Ultomiris)
2024-LHCC-MED-570 Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta) 6/6/24 7/21/24 Pending Bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta)
2024-LHCC-MED-571 Daptomycin (Cubicin, Cubicin RF, Dapzura RT) 6/6/24 7/21/24 Pending Daptomycin (Cubicin, Cubicin RF, Dapzura RT)
2024-LHCC-MED-572 Bortezomib (Velcade) 6/6/24 7/21/24 Pending Bortezomib (Velcade)
2024-LHCC-MED-573 Efgartigimod Alfa-fcab (Vyvgart) 6/6/24 7/21/24 Pending Efgartigimod Alfa-fcab (Vyvgart)
2024-LHCC-MED-574 Pemetrexed (Alimta, Pemfexy) 6/6/24 7/21/24 Pending Pemetrexed (Alimta, Pemfexy)
2024-LHCC-MED-531 Ferumoxytol (Feraheme) 6/4/24 7/19/24 Pending Ferumoxytol (Feraheme)
2024-LHCC-MED-532 Ibandronate injection (Boniva) 6/4/24 7/19/24 Pending Ibandronate injection (Boniva)
2024-LHCC-MED-533 Ferric Carboxymaltose (Injectafer) 6/4/24 7/19/24 Pending Ferric Carboxymaltose (Injectafer)
2024-LHCC-MED-511 Iptacopan (Fabhalta) 6/4/24 7/19/24 Pending Iptacopan (Fabhalta)
2024-LHCC-MED-512 Toripalimab-tpzi (Loqtorzi) 6/4/24 7/19/24 Pending Toripalimab-tpzi (Loqtorzi)
2024-LHCC-MED-513 Aprocitentan (Tryvio) 6/4/24 7/19/24 Pending Aprocitentan (Tryvio)
2024-LHCC-MED-514 Vadadustat (Vafseo) 6/4/24 7/19/24 Pending Vadadustat (Vafseo)
2024-LHCC-MED-515 Edaravone (Radicava) 6/4/24 7/19/24 Pending Edaravone (Radicava)
2024-LHCC-MED-516 Triamcinolone ER Injection (Zilretta) 6/4/24 7/19/24 Pending Triamcinolone ER Injection (Zilretta)
2024-LHCC-MED-517 Epoprostenol (Flolan, Veletri) 6/4/24 7/19/24 Pending Epoprostenol (Flolan, Veletri)
2024-LHCC-MED-518 Hemin (Panhematin) 6/4/24 7/19/24 Pending Hemin (Panhematin)
2024-LHCC-MED-519 Verteporfin (Visudyne) 6/4/24 7/19/24 Pending Verteporfin (Visudyne)
2024-LHCC-MED-520 Cosyntropin (Cortrosyn) 6/4/24 7/19/24 Pending Cosyntropin (Cortrosyn)
2024-LHCC-MED-521 Asfotase Alfa (Strensiq) 6/4/24 7/19/24 Pending Asfotase Alfa (Strensiq)
2024-LHCC-MED-522 Protein C Concentrate Human (Ceprotin) 6/4/24 7/19/24 Pending Protein C Concentrate Human (Ceprotin)
2024-LHCC-MED-523 Voretigene Neparvovec-rzyl (Luxturna) 6/4/24 7/19/24 Pending Voretigene Neparvovec-rzyl (Luxturna)
2024-LHCC-MED-524 Inotersen (Tegsedi) 6/4/24 7/19/24 Pending Inotersen (Tegsedi)
2024-LHCC-MED-525 Trofinetide (Daybue) 6/4/24 7/19/24 Pending Trofinetide (Daybue)
2024-LHCC-MED-526 Eculizumab (Soliris) 6/4/24 7/19/24 Pending Eculizumab (Soliris)
2024-LHCC-MED-527 Agalsidase beta (Fabrazyme) 6/4/24 7/19/24 Pending Agalsidase beta (Fabrazyme)
2024-LHCC-MED-528 Interferon Gamma-1b (Actimmune) 6/4/24 7/19/24 Pending Interferon Gamma-1b (Actimmune)
2024-LHCC-MED-529 Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars 6/4/24 7/19/24 Pending Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars
2024-LHCC-MED-530 Sutimlimab-jome (Enjaymo) 6/4/24 7/19/24 Pending Sutimlimab-jome (Enjaymo)
2024-LHCC-MED-497 Idecabtagene Vicleucel (Abecma) 5/23/24 7/7/24 Pending Idecabtagene Vicleucel (Abecma)
2024-LHCC-MED-428 Ofatumumab (Arzerra) 5/23/24 7/7/24 Pending Ofatumumab (Arzerra)
2024-LHCC-MED-431 Lisocabtagene maraleucel (Breyanzi) 5/23/24 7/7/24 Pending Lisocabtagene maraleucel (Breyanzi)
2024-LHCC-MED-481 Levoleucovorin (Fusilev, Khapzory) 5/23/24 7/7/24 Pending Levoleucovorin (Fusilev, Khapzory)
2024-LHCC-MED-482 Obinutuzumab (Gazyva) 5/23/24 7/7/24 Pending Obinutuzumab (Gazyva)
2024-LHCC-MED-483 Eribulin Mesylate (Halaven) 5/23/24 7/7/24 Pending Eribulin Mesylate (Halaven)
2024-LHCC-MED-484 Panitumumab (Vectibix) 5/23/24 7/7/24 Pending Panitumumab (Vectibix)
2024-LHCC-MED-485 Temsirolimus (Torisel) 5/23/24 7/7/24 Pending Temsirolimus (Torisel)
2024-LHCC-MED-486 Gemtuzumab Ozogamicin (Mylotarg)  5/23/24 7/7/24 Pending Gemtuzumab Ozogamicin (Mylotarg) 
2024-LHCC-MED-487 Inotuzumab Ozogamicin (Besponsa) 5/23/24 7/7/24 Pending Inotuzumab Ozogamicin (Besponsa)
2024-LHCC-MED-488 Eteclacalcetide (Parsabiv) 5/23/24 7/7/24 Pending Eteclacalcetide (Parsabiv)
2024-LHCC-MED-489 Leucovorin Injection 5/23/24 7/7/24 Pending Leucovorin Injection
2024-LHCC-MED-490 Vincristine Sulfate Liposome Injection (Marqibo) 5/23/24 7/7/24 Pending Vincristine Sulfate Liposome Injection (Marqibo)
2024-LHCC-MED-491 Lanreotide (Somatuline Depot and Unbranded) 5/23/24 7/7/24 Pending Lanreotide (Somatuline Depot and Unbranded)
2024-LHCC-MED-461 Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispha, Ozabax) 5/23/24 7/7/24 Pending Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispha, Ozabax)
2024-LHCC-MED-462 Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) 5/23/24 7/7/24 Pending Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas)
2024-LHCC-MED-463 Hyaluronate Derivatives 5/23/24 7/7/24 Pending Hyaluronate Derivatives
2024-LHCC-MED-464 Burosumab-twza (Crysvita) 5/23/24 7/7/24 Pending Burosumab-twza (Crysvita)
2024-LHCC-MED-465 Collagenase Clostridium Histolyticum (Xiaflex) 5/23/24 7/7/24 Pending Collagenase Clostridium Histolyticum (Xiaflex)
2024-LHCC-MED-466 Thyrotropin Alfa (Thyrogen) 5/23/24 7/7/24 Pending Thyrotropin Alfa (Thyrogen)
2024-LHCC-MED-467 Mogamulizumab-kpkc (Poteligeo) 5/23/24 7/7/24 Pending Mogamulizumab-kpkc (Poteligeo)
2024-LHCC-MED-468 Degarelix Acetate (Firmagon) 5/23/24 7/7/24 Pending Degarelix Acetate (Firmagon)
2024-LHCC-MED-469 Belinostat (Beleodaq) 5/23/24 7/7/24 Pending Belinostat (Beleodaq)
2024-LHCC-MED-470 Pralatrexate (Folotyn) 5/23/24 7/7/24 Pending Pralatrexate (Folotyn)
2024-LHCC-MED-471 Necitumumab (Portrazza) 5/23/24 7/7/24 Pending Necitumumab (Portrazza)
2024-LHCC-MED-472 Ziv-aflibercept (Zaltrap) 5/23/24 7/7/24 Pending Ziv-aflibercept (Zaltrap)
2024-LHCC-MED-473 Daunorubicin-cytarabine (Vyxeos) 5/23/24 7/7/24 Pending Daunorubicin-cytarabine (Vyxeos)
2024-LHCC-MED-474 Copanlisib (Aliqopa) 5/23/24 7/7/24 Pending Copanlisib (Aliqopa)
2024-LHCC-MED-475 Chloramphenicol Sodium Succinate 5/23/24 7/7/24 Pending Chloramphenicol Sodium Succinate
2024-LHCC-MED-476 Pegvisomant (Somavert) 5/23/24 7/7/24 Pending Pegvisomant (Somavert)
2024-LHCC-MED-477 Iobenguane I-131 (Azedra) 5/23/24 7/7/24 Pending Iobenguane I-131 (Azedra)
2024-LHCC-MED-478 Isatuximab-irfc (Sarclisa) 5/23/24 7/7/24 Pending Isatuximab-irfc (Sarclisa)
2024-LHCC-MED-479 Sirolimus Protein-Bound Particles (Fyarro) 5/23/24 7/7/24 Pending Sirolimus Protein-Bound Particles (Fyarro)
2024-LHCC-MED-480  Sodium Phenylbutyrate-Taurursodiol (Relyvrio) 5/23/24 7/7/24 Pending Sodium Phenylbutyrate-Taurursodiol (Relyvrio)
2024-LHCC-MED-453 Amivantamab-vmjw (Rybrevant)  5/21/24 7/5/24 Pending Amivantamab-vmjw (Rybrevant) 
2024-LHCC-MED-458 Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda) 5/21/24 7/5/24 Pending Cipaglucosidase alfa-atga--miglustat (Pombiliti-Opfolda)
2024-LHCC-MED-459  Eplontersen (Wainua) 5/21/24 7/5/24 Pending Eplontersen (Wainua)
2024-LHCC-MED-460 ADAMTS13, recombinant-krhn (Adzynma) 5/21/24 7/5/24 Pending ADAMTS13, recombinant-krhn (Adzynma)
2024-LHCC-MED-501 Aflibercept (Eylea, Eylea HD) 5/21/24 7/5/24 Pending Aflibercept (Eylea, Eylea HD)
2024-LHCC-MED-502 Romidepsin (Istodax) 5/21/24 7/5/24 Pending Romidepsin (Istodax)
2024-LHCC-MED-503 Pasireotide (Signifor, Signifor LAR) 5/21/24 7/5/24 Pending Pasireotide (Signifor, Signifor LAR)
2024-LHCC-MED-504 Avalglucosidase Alfa-ngpt (Nexviazyme) 5/21/24 7/5/24 Pending Avalglucosidase Alfa-ngpt (Nexviazyme)
2024-LHCC-MED-505 Ropeginterferon Alfa-2b-njft (BESREMi) 5/21/24 7/5/24 Pending Ropeginterferon Alfa-2b-njft (BESREMi)
2024-LHCC-MED-506 Olipudase Alfa-rpcp (Xenpozyme) 5/21/24 7/5/24 Pending Olipudase Alfa-rpcp (Xenpozyme)
2024-LHCC-MED-507 Tofersen (Qalsody) 5/21/24 7/5/24 Pending Tofersen (Qalsody)
2024-LHCC-MED-492 Treprostinil (Remodulin) 5/21/24 7/5/24 Pending Treprostinil (Remodulin)
2024-LHCC-MED-493 Belatacept (Nulojix) 5/21/24 7/5/24 Pending Belatacept (Nulojix)
2024-LHCC-MED-494 Mitoxantrone 5/21/24 7/5/24 Pending Mitoxantrone
2024-LHCC-MED-495 Irinotecan Liposome (Onivyde)  5/21/24 7/5/24 Pending Irinotecan Liposome (Onivyde) 
2024-LHCC-MED-496 Plerixafor (Mozobil) 5/21/24 7/5/24 Pending Plerixafor (Mozobil)
2024-LHCC-MED-498 Pertuzumab-Trastuzumab-Hyaluronidase-zzxf (Phesgo) 5/21/24 7/5/24 Pending Pertuzumab-Trastuzumab-Hyaluronidase-zzxf (Phesgo)
2024-LHCC-MED-499 Antithymocyte Globulin (Atgam, Thymoglobulin) 5/21/24 7/5/24 Pending Antithymocyte Globulin (Atgam, Thymoglobulin)
2024-LHCC-MED-500 Talimogene laherepvec (Imlygic) 5/21/24 7/5/24 Pending Talimogene laherepvec (Imlygic)
2024-UHC-MED-212 Complement inhibitors 5/21/24 7/5/24 Pending Complement inhibitors
2024-UHC-MED-211 Review at Launch New to Market Medications 5/16/24 6/30/24 Pending Review at Launch New to Market Medications
2024-PHARM-36 Acne Agents 5/15/24 6/29/24 Pending Acne Agents
2024-PHARM-37 Anticonvulsants 5/15/24 6/29/24 Pending Anticonvulsants
2024-PHARM-38 Asthma-COPD, Beta-Adrenergic Bronchodilators 5/15/24 6/29/24 Pending Asthma-COPD, Beta-Adrenergic Bronchodilators
2024-PHARM-39 Asthma-COPD, Inhaled Anticholinergic Bronchodilators 5/15/24 6/29/24 Pending Asthma-COPD, Inhaled Anticholinergic Bronchodilators
2024-PHARM-40 Asthma-COPD, Inhaled Glucocorticoids 5/15/24 6/29/24 Pending Asthma-COPD, Inhaled Glucocorticoids
2024-PHARM-41 Dermatology-Topical, Antiparasitic Agents 5/15/24 6/29/24 Pending Dermatology-Topical, Antiparasitic Agents
2024-PHARM-42 Digestive Disorders, PPIs 5/15/24 6/29/24 Pending Digestive Disorders, PPIs
2024-PHARM-43 Digestive Disorders, Ulcerative Colitis Agents 5/15/24 6/29/24 Pending Digestive Disorders, Ulcerative Colitis Agents
2024-PHARM-44 GI Motility, Chronic 5/15/24 6/29/24 Pending GI Motility, Chronic
2024-PHARM-45 Heart Disease, Anticoagulants 5/15/24 6/29/24 Pending Heart Disease, Anticoagulants
2024-PHARM-46 Heart.Disease, Pulmonary Arterial Hypertension Agents 5/15/24 6/29/24 Pending Heart.Disease, Pulmonary Arterial Hypertension Agents
2024-PHARM-47 Hemodialysis, Phosphate Binders 5/15/24 6/29/24 Pending Hemodialysis, Phosphate Binders
2024-PHARM-48 Infectious Disorders, Hepatitis C DAA 5/15/24 6/29/24 Pending Infectious Disorders, Hepatitis C DAA
2024-PHARM-49 Infectious Disorders-Antibiotics, Inhaled Antibiotics 5/15/24 6/29/24 Pending Infectious Disorders-Antibiotics, Inhaled Antibiotics
2024-PHARM-50 Multiple Sclerosis Agents 5/15/24 6/29/24 Pending Multiple Sclerosis Agents
2024-PHARM-51 Oncology Agents-Oral, Hematologic 5/15/24 6/29/24 Pending Oncology Agents-Oral, Hematologic
2024-PHARM-52 Ophthalmic Disorders-Anti-Inflammatory, Immunomodulators 5/15/24 6/29/24 Pending Ophthalmic Disorders-Anti-Inflammatory, Immunomodulators
2024-PHARM-53 Ophthalmic Disorders-Glaucoma.Agents, Intraocular Pressure Reducers 5/15/24 6/29/24 Pending Ophthalmic Disorders-Glaucoma.Agents, Intraocular Pressure Reducers
2024-PHARM-54 Opiate Dependence Agents 5/15/24 6/29/24 Pending Opiate Dependence Agents
2024-PHARM-55 PDL-July 1, 2024 5/15/24 6/29/24 Pending PDL-July 1, 2024
2024-PHARM-56 POS Infectious Disorders-Hepatitis C Agents, Direct Acting Antiviral Agents 5/15/24 6/29/24 Pending POS Infectious Disorders-Hepatitis C Agents, Direct Acting Antiviral Agents
2024-PHARM-57 Stimulants and Related Agents 5/15/24 6/29/24 Pending Stimulants and Related Agents
2024-PHARM-58 Wegovy 5/15/24 6/29/24 Pending Wegovy
2024-PHARM-59 Wegovy Patient Agreement 5/15/24 6/29/24 Pending Wegovy Patient Agreement

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