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 1-800-684-5502. We will look up your member ID number and share it with your pharmacy.
- Call our Pharmacy Member Services team at 1-866-452-1040 (TTY 1-855-294-7047) 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 medically necessary pharmaceuticals to AmeriHealth Caritas Louisiana members.
Direct all questions related to pharmacy services, including those about claims and prior authorizations, to PerformRx Provider Services at 1-800-684-5502 or fax to 1-855-452-9131.
Formulary
Effective May 1, 2019, AmeriHealth Caritas Louisiana is using the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF), which contains a complete list of preferred products.
Direct prior authorization requests for medications to AmeriHealth Caritas Louisiana/PerformRx Pharmacy Services at 1-800-684-5502 or fax to 1-855-452-9131.
Continue to direct prior authorization requests for medical injectable (provider-administered) medications to AmeriHealth Caritas Louisiana/PerformRx at 1-800-684-5502 or fax to 1-855-452-9131.
Coverage of brand name products
With few exceptions, 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 the Louisiana Medicaid Single PDL (Fee for Service and Managed Care Organizations) (PDF) for exceptions to the generic requirement (brand name preferred/generic non-preferred).
Prior authorization
In a continuing effort to improve patient care and pharmaceutical utilization, AmeriHealth Caritas Louisiana has implemented a prior authorization (PA) program for certain medications. PA requests for medications should be directed to PerformRx at 1-800-684-5502 or faxed to 1-855-452-9131.
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. 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 1-800-684-5502.
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 7328
London, KY 40742
Or fax: 1-888-913-0362
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 to AmeriHealth Caritas Louisiana.
Copayments
Effective January 1, 2020, AmeriHealth Caritas Louisiana will implement measures to ensure that copays of Medicaid family members do not exceed 5% of the family income. Copay amounts will stop once the monthly threshold is met.
Learn more about copay limits (PDF).
Some adult members (21 years of age or older) are subject to a sliding copayment per prescription. The following table shows the copayment amounts:
| Copayment | Calculated State Payment |
|---|---|
| $0.00 | $5.00 or less |
| $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 |
There will be no copay for members who are, for example:
- 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.