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Pharmacy services

Important information about member pharmacy benefits.

If you need to fill a prescription before you get your new ID card:

  • Use your current ID card at the pharmacy. The pharmacy will contact us for other information needed to fill your prescription.
  • If you don’t have your current ID card when you go to fill your prescription, tell the pharmacy to call Pharmacy Provider Services at 800-684-5502. We will look up your member ID number and share it with your pharmacy.
  • Call our Pharmacy Member Services team at 866-452-1040 (TTY 855-294-7047) if you need help or have questions.

AmeriHealth Caritas Louisiana provides pharmacy benefits to members. PerformRx manages AmeriHealth Caritas Louisiana’s pharmacy services. Through valid prescriptions, licensed providers may prescribe a maximum 30-day supply of medically-necessary pharmaceuticals to AmeriHealth Caritas Louisiana members. AmeriHealth Caritas Louisiana covers certain over-the-counter (OTC) drugs when a licensed provider prescribes them.

Direct all questions related to pharmacy services, including those about claims and prior authorizations, to PerformRx Provider Services at 800-684-5502 or fax to 855-452-9131.


Formulary

AmeriHealth Caritas Louisiana maintains a comprehensive formulary. The formulary represents therapeutic recommendations based on documented clinical efficacy, safety and cost-effectiveness. All non-preferred medications will require prior authorization. AmeriHealth Caritas Louisiana's criteria require a trial and failure or intolerance of one to three preferred medications, depending on the class. Please view our searchable formulary for a complete list of preferred products.

Direct requests for prior authorization medications to AmeriHealth Caritas Louisiana/PerformRx Pharmacy Services at 800-684-5502 or fax to 855-452-9131.

Providers may request the addition of a medication to the formulary. Requests must include the drug name, rationale for inclusion on the formulary, role in therapy, and medications that may be replaced by the addition. Please direct such requests to the Pharmacy and Therapeutics Committee at:

AmeriHealth Caritas Southern Region P&T Committee
P.O. Box 40849
Charleston, SC 29423

Please specify in your request that it is for addition to the AmeriHealth Caritas Louisiana Formulary.

NOTE: Experimental drugs, procedures or equipment not approved by Medicaid are excluded.

P&T Committee request form for a formulary addition, deletion or modification

Coverage of brand name products

Prior authorization is required for brand name products for which there are "A"-rated, therapeutically equivalent, less costly generics available. Prescribers who wish to prescribe brand name products must furnish documentation of generic treatment failure prior to dispensing. The treatment failure must be directly attributed to the patient's use of a generic form of the brand name product. Please view our searchable formulary for exceptions to the generic requirement.

Prior authorization

In a continuing effort to improve patient care and pharmaceutical utilization, AmeriHealth Caritas Louisiana, in conjunction with PerformRx, has implemented a prior authorization (PA) program for the initial prescription of certain medications. Requests for PA medications should be directed to PerformRx at 800-684-5502 or faxed to 855-452-9131.

In most cases where the prescribing health care professional/provider has not obtained prior authorization, members will receive a three-day supply of the medication and PerformRx may make a request for clinical information to the prescriber. All clinical information requests must be completed within three days from initial request. To request these medications, download and complete the prior authorization request form.

Prescribers may request copies of the criteria used to make the Prior Authorization determination by contacting PerformRx at 800-684-5502.

Appeal of prior authorization denials

The prescriber or the PCP, with the member's written consent, may ask for reevaluation on any denied prior authorization request or suggested alternative by contacting AmeriHealth Caritas Louisiana Appeals in writing at:

AmeriHealth Caritas Louisiana Appeals
P.O. Box 7324
London, KY 40743

Or fax: 877-724-4835

Continuity of care (transition supply)

AmeriHealth Caritas Louisiana will provide coverage of prescriptions taken on a regular basis for chronic conditions (maintenance medicines) that are not on the AmeriHealth Caritas Louisiana formulary for at least 60 days after the member's transition from the fee-for-service pharmacy program. AmeriHealth Caritas Louisiana will provide supplies of antidepressant and antipsychotic medicines for at least 90 days after the transition.

Over-the-counter drugs

All members are covered for certain over-the-counter (OTC) drugs with a prescription written by a doctor. Products will be dispensed generically when available as outlined above. There are some restrictions that apply.

Co-payments

Some adult members (21 years of age or older) are subject to a sliding co-payment per prescription. The following table shows the co-payment amounts:

Co-payment Amount Calculated State Payment
$0.50 $10.00 or less
$1.00 $10.01 to $25.00
$2.00 $25.01 to $50.00
$3.00 $50.01 or more

The following members are exempt from the co-payment:

  • Less than 21 years of age
  • Pregnant
  • Receiving emergency services
  • Residing in long-term care facilities or other institutions
  • Federally-recognized as Native Americans or Alaskan Eskimos

Members must pick up medications at a pharmacy that is within the AmeriHealth Caritas Louisiana network. Please use our Find a Pharmacy tool to search our participating pharmacies.