RA Messages for May 5, 2009


If you are unsure about the coverage of a drug product, please contact the PBM help desk at 1-800-648-0790.


Please note the following changes to Appendix A

      DRUG                                                             DOSE                           STRG                            LMAC                     EFF.   

ALBUTEROL SULFATE                                  VIAL-NEB                    2.5MG/0.5ML              OFF MAC              04/21/09

BETAMETHASONE DIPROPIONATE              POWDER                                                        OFF MAC              04/21/09

BUPIVACAINE HCL                                         POWDER                         100                          OFF MAC              04/21/09

CAPTOPRIL/HCTZ                                             TABLET                     50M-15MG                  OFF MAC              04/21/09

CEFOXITIN SODIUM                                         VIAL                              10G                          OFF MAC             04/21/09

CEFUROXIME SODIUM                                    VIAL 25ML                 750MG                       OFF MAC             04/21/09

CEFUROXIME SODIUM                                    VIAL 1ML                   750MG                       OFF MAC             04/21/09

CHLORTHALIDONE                                        TABLET                          25MG                        OFF MAC             04/21/09

COCAINE HCL                                               SOLUTION                        10%                         OFF MAC             04/21/09

COCAINE HCL                                               SOLUTION                         4%                          OFF MAC             04/21/09

CROMOLYN SODIUM                                    POWDER                                                          OFF MAC             04/21/09

CYCLOBENZAPRINE HCL                             POWDER                        100%                        OFF MAC             04/21/09

DEXAMETHASONE                                         TABLET                         0.5MG                       OFF MAC             04/21/09

DEXAMETHASONE SOD PHOS/PF                  VIAL                          10MG/ML                   OFF MAC             04/21/09

DEXCHLORPHENIRAMINE MALEATE          TAB SA                           6MG                        OFF MAC             04/21/09

DIAZEPAM                                                          VIAL                            5MG/ML                    OFF MAC            04/21/09

DOPAMINE HCL/DEXTROSE 5%                  INFUS BTL                     800MG/0.5L              OFF MAC            04/21/09

DOXEPINE HCL                                              ORAL CONC                   10MG/ML                OFF MAC            04/21/09

FE BISGLY/FE PS CMPLX/VIT                      C CAPSULE                     150-50MG               OFF MAC             04/21/09

FERROUS SULFATE/VIT C/FA                      TABLET SA                     105-500-.8               OFF MAC             04/21/09

FLUOCINOLONE ACETONIDE                    CREAM 60GM                    0.025%                  OFF MAC            04/21/09

FLUOCINOLONE ACETONIDE                    CREAM 15GM                     0.025%                 OFF MAC            04/21/09

FLUPHENAZINE DECANOATE                       VIAL                                25MG/ML               OFF MAC            04/21/09

FOLIC ACID/MULTIVITS-MIN                     TABLET                                 1MG                    OFF MAC            04/21/09

GUAIFENESIN/P-EPHED HCL                      TAB SR 12H                   600MG-120MG          OFF MAC            04/21/09

GUAIFENESIN/P-EPHED HCL                      TAB SR 12H                       700-80MG              OFF MAC            04/21/09

GUAIFENESIN/P-EPHED HCL                      TAB SR 12H                   795MG-85MG            OFF MAC            04/21/09

GUAIFENESIN/P-EPHED HCL                      TAB SR 12H                       800-45MG              OFF MAC            04/21/09

GUAIFENESIN/P-EPHED HCL                      TAB SR 12H                    800MG-60MG           OFF MAC            04/21/09

GUAIFENESIN/PHENYLEPHRINE              TAB SR 12H                         275-25MG             OFF MAC            04/21/09

GUAIFENESIN/PHENYLEPHRINE              TAB SR 12H                       600MG-20MG         OFF MAC            04/21/09

HOMATROPINE HBR                                   DROPS                                        5%                   OFF MAC            04/21/09

HYDROCORTISONE                                    LOTION                                      1%                   OFF MAC            04/21/09

HYOSCYAMINE SULFATE                         CAP SR 12H                           0.375MG              OFF MAC            04/21/09

IMMUNE GLOBULIN,GAMMA(IGG)         VIAL                                             5G                  OFF MAC             04/21/09

IPRATROPIUM BROMIDE                           POWDER                                                            OFF MAC             04/21/09

ISONIAZID                                                    TABLET                                   100MG               OFF MAC             04/21/09

KETOPROFEN                                              CAP24H PEL                           200MG               OFF MAC             04/21/09

KETOROLAC TROMETHAMINE               CARTRIDGE                          15MG/ML             OFF MAC            04/21/09

LEVOBUNOLOL HCL                                 DROPS                                       0.25%                OFF MAC            04/21/09

METHYLPREDNISOLONE SOD SUCC     VIAL                                       125MG/2ML         OFF MAC            04/21/09

METHYLTESTOSTERONE                         POWDER 5GM                                                     OFF MAC           04/21/09

METHYLTESTOSTERONE                         POWDER 25GM                                                   OFF MAC           04/21/09

METOPROL/HCTZ                                      TABLET                                   100-50MG            OFF MAC            04/21/09

MEXILETINE HCL                                      CAPSULE                                  150MG                OFF MAC           04/21/09

MEXILETINE HCL                                      CAPSULE                                  200MG                OFF MAC           04/21/09

MEXILETINE HCL                                      CAPSULE                                  250MG                OFF MAC           04/21/09

MIDAZOLAM HCL                                     DISP SYRIN                             5MG/ML              OFF MAC           04/21/09

MORPHINE SULFATE                               POWDER                                     100%                 OFF MAC           04/21/09

NAFCILLIN SODIUM                                VIAL PORT                                     1G                  OFF MAC           04/21/09

NEOMYCIN SULFATE                              POWDER 100GM                                                  OFF MAC           04/21/09

NEOMYCIN SULFATE                              POWDER 10GM                                                    OFF MAC           04/21/09

NEOSTIGMINE METHYLSULFATE         VIAL                                            1:2000                OFF MAC           04/21/09

NITROGLYCERIN                                     CAPSULE SA                                 9MG                OFF MAC          04/21/09

P-EPHED HCL/BROMPHENIRAMINE    CAPSULE SA                               60-6MG             OFF MAC           04/21/09

P-EPHED SUL/LORATADINE                  TAB SR 12H                                                            OFF MAC           04/21/09

PERGOLIDE MESYLATE                          TABLET                                           1MG               OFF MAC           04/21/09

PERGOLIDE MESYLATE                          TABLET                                         0.25MG            OFF MAC            04/21/09

PHENOBARBITAL                                    VIAL                                           125MG/2ML        OFF MAC            04/21/09

PHENYLEPHRINE HCL                           VIAL                                              10MG/ML          OFF MAC            04/21/09

PHENYLEPHRINE/CHLOR-MAL/SCOP    SOLUTION                               10-2-1.25            OFF MAC           04/21/09

PHENYLEPHRINE/PYRIL TAN/CP         ORAL SUSP                                 5-12.5-2/5           OFF MAC           04/21/09

PNV W-O CA NO3/FE FUMARATE/FA     CAPSULE                               106MG-1MG        OFF MAC           04/21/09

PRENATAL VIT/FE FUMARATE/FA         TABLET                                      29MG-1MG       OFF MAC            04/21/09

PROCAINAMIDE HCL                              CAPSULE                                      250MG             OFF MAC            04/21/09

PROPRANOLOL HCL                                VIAL                                             1MG/ML           OFF MAC            04/21/09

PROPRANOLOL/HCTZ                              TABLET                                       80-25MG           OFF MAC            04/21/09

PSEUDOEPHE TAN/DEXCHLOR TAN      ORAL SUSP                              75-2.5MG/5        OFF MAC            04/21/09

PSEUDOEPHEDRINE HCL/CHLOR-MAL         CAP SR 12H                      60MG-4MG        OFF MAC           04/21/09

PSEUDOEPHEDRINE/CPM/METHSCOPOL     TAB SR 12H                         90-8-2.5           OFF MAC            04/21/09

SELEGILINE HCL                                        TABLET                                         5MG               OFF MAC            04/21/09

SELEGILINE HCL                                        CAPSULE                                      5MG               OFF MAC            04/21/09

SODIUM FLUORIDE                                       DROPS                                    0.5MG/ML        OFF MAC            04/21/09

TETRACAINE HCL                                         DROPS                                        0.5%               OFF MAC            04/21/09

THEOPHYLLINE ANHYDROUS                   CAP SR 12H                             300MG             OFF MAC              04/21/09 

HYOSCYAMINE SULFATE                          TAB SR 12H                             0.375MG              1.31843               04/28/09 


Please file adjustments for claims that may have been incorrectly paid. Only those products of the manufacturers which participate in the Federal Rebate Program will be covered by the Medicaid program. Participation may be verified in Appendix C, available at www.lamedicaid.com


For Medicaid pharmacy services effective May 1, 2009, the Department of Health and Hospitals, Bureau of Health Services Financing will establish a five-prescription limit per recipient per calendar month. Please refer to www.lamedicaid.com for detailed information.


Effective with date of processing June 1, 2009, service providers will be required to transmit the PCP's 10-digit NPI as the CommunityCARE Referral Authorization Number on EDI claims transactions. A detailed provider notice, containing important information for both PCPs and servicing providers that must have a referral, is posted on the homepage of the LA Medicaid website, www.lamedicaid.com. Please visit the website to obtain this needed information in order to make all necessary changes and be prepared for this transition to avoid unnecessary claim denials.


Updates to the Pharmacy Benefits Management Services Manual are now available on the Louisiana Medicaid website at www.lamedicaid.com. Pharmacy providers should refer to the manual for a complete description of Medicaid pharmacy program policy.