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Pharmacy

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Effective January 1, 2023, the Louisiana Medicaid Pharmacy Program now consists of Fee for Service (FFS) Medicaid and six Managed Care Organizations (MCO). Humana Healthy Horizons® in Louisiana is the newest MCO and utilizes Prime Therapeutics State Government Solutions Pharmacy Benefits Manager. Please submit pharmacy claims for Medicaid recipients with coverage through Humana Healthy Horizons online at Point of Sale (POS) to Prime Therapeutics State Government Solutions.

If you have pharmacy processing issues, please call the Prime Therapeutics Pharmacy Help Desk: 1-800-424-1664.

Pharmacy prior authorization

The process by which medication is supplied by a pharmacy and billed through the pharmacy benefit includes medication prior authorization (PA), quantity limits, and medication exceptions.

Prior authorizations are obtained through the Prime Therapeutics State Government Solutions. Prior authorizations can be requested by phone, fax, mail, or electronic submissions:

Phone submissions: 1-800-424-1664

Faxed submissions: 1-800-424-7402

Electronic submissions: CoverMyMeds

Providers can find pharmacy prior authorization fax forms from LDH or by calling 1-800-424-1664, 24 hours a day, 7 days a week.

Physician-administered drug prior authorization

The Humana Healthy Horizons in Louisiana Preauthorization and Notification List describe services and medications that are commonly reviewed and may require additional clinical information. Medications include those delivered in the physician’s office, clinic, and outpatient or home setting.

About Humana Healthy Horizons in Louisiana

Humana Healthy Horizons in Louisiana members get prescription drug coverage through Prime Therapeutics State Government Solutions pharmacy benefit manager (PBM).

Prime Therapeutics State Government Solutions PBM provides pharmacy benefits for all Medicaid recipients in Louisiana. The Louisiana Department of Health utilizes a single Preferred Drug List (PDL).

The PDL includes some preferred brands, as well as preferred diabetic supplies, such as blood glucose strips, lancets, meters, and syringes. The Louisiana Department of Health will notify providers if the PDL changes.

Medication on the PDL may have a small copayment for members 21 and older, based on calculated state payment(s). However, there are no copayments for medication on the PDL for the following types of members:

Alaskan Eskimos

Members 20 and younger

Members receiving hospice services

Members receiving services on the basis of breast or cervical cancer diagnoses

Members who are inpatients in long-term care facilities or other institutions

Native Americans

Pregnant members

There never is a copayment for family-planning services and supplies and/or emergency services.

Access the PDL.

Medication Therapy Management

Humana offers a Medication Therapy Management (MTP) program that helps ensure your eligible patients achieve the best possible outcomes from their medications. The patient-centered MTM program promotes collaboration among the pharmacist, patient, and prescriber to optimize safe and effective medication use. The goal of this program is to optimize therapeutic outcomes by focusing on safety, effectiveness, lower-cost alternatives, and adherence.

Prescribers with questions about the program may call 1-888-210-8622 (TTY: 711), Monday – Friday, from 7 a.m. – 6 p.m.

Pharmacy lock-in program

The lock-in program is designed for individuals enrolled in Medicaid in Louisiana who need help managing their use of prescription medications. The Louisiana Department of Health requires us to use a lock-in program to help limit overuse of benefits, reduce unnecessary costs to Medicaid, and provide an appropriate level of care for our members.

Humana Healthy Horizons® in Louisiana members who meet lock-in program criteria will be locked into one pharmacy and/or one prescriber (group). A specialty pharmacy will be added on an as needed basis.

To identify members who meet lock-in program criteria, we monitor claims activity for signs of misuse or abuse in accordance with state and federal laws. If this review reveals an unusually large number of controlled-substance prescriptions or misuse of prescriptions, we will notify the member in writing of their enrollment in the lock-in program and provide the designated lock-in pharmacy and/or prescriber (group) information.

Over-the-counter health and wellness

Humana Healthy Horizons in Louisiana members have an expanded pharmacy benefit, which provides up to $25 per calendar month allowance to spend on over-the-counter (OTC) medicine, like pain relievers, diaper rash cream, cough and cold medicine, and first-aid supplies.

These items will be sent by mail within 10-14 working days of receiving a member’s order. Members do not pay shipping charges.

If you have questions about this mail-order service, call CenterWell Pharmacy™ at 1-855-211-8370 (TTY: 711), Monday – Friday, from 7 a.m. – 10 p.m., and Saturday, from 7:30 a.m. – 5:30 p.m.

Over-the-counter value-added benefit catalog and order form – English

Over-the-counter value-added benefit catalog and order form – Spanish

NCPDP Field	Field name	Billing information
332-CY	PATIENT ID	Humana ID OR MEDICAID ID
101-A1	BIN	025986
104-A4	PCN	1214172240
301-C1	GROUP ID	LAMPCOPBM

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