Current through Register Vol. 50, No. 9, September 20, 2024
A.
Reimbursement for multi-source prescription drugs shall be limited in
accordance with state and federal law and rules pertaining thereto, with the
following exception: reimbursement shall be provided for any drug prescribed by
a prescribing provider that, in his professional judgment and within the lawful
scope of his practice, he considers appropriate for the diagnosis and treatment
of the patient with the following limitations.
1. The prescribed drug has been approved and
designated as safe and effective by the Food and Drug Administration.
2. The prescribed drug is not classified as a
DESI drug (drugs which have been identified by the FDA as lacking evidence of
safety/effectiveness).
3. The
prescribed drug is not a compounded prescription (mixtures of two or more
ingredients).
4. The prescribed
drug is not methadone prescribed only for narcotic addiction.
5. The prescription is not for medications
which are included in the reimbursement to Title XIX facilities, including, but
not limited to:
a. hospitalized
recipients;
b. recipients receiving
benefits under Part A of Title XVIII in a skilled nursing facility;
or
c. resident/patients at Villa
Feliciana or any state mental hospital.
6. The prescribed drug is an excluded or
otherwise restricted drug.
7. The
prescribed drug is not an experimental or investigational drug which are
generally labeled:
Caution-limited by federal law to investigational use, unless
a specific exception has been granted by the federal government.
8. The prescribed drug is not an
immunosuppresant drug prescribed and billed to Medicare for a Title XIX
transplant recipient who has Medicare Part B coverage.
9. The prescribed drug is not an
immunosuppressant drug covered by Medicare Part B which is prescribed for a
nontransplant patient with Medicare Part B coverage and identified in the Title
XIX provider manual as subject to special billing procedures.
B. Drug Listing
1. The bureaus fiscal intermediary or agent
will provide coverage information on any specific drug. Providers should
contact the fiscal intermediarys or agents provider/pharmacy relations unit
when a specific coverage question arises.
2. The Title XIX provider manual shall
include a listing of examples of prescribed medications and/or supplies which
are not payable under pharmaceutical services of the Medicaid
Program.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.