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.
Effective May 1, 2019, AmeriHealth Caritas Louisiana will be using the Louisiana Medicaid Single PDL (Fee For Service and Managed Care Organizations) (PDF), which contains a complete list of preferred products.
Direct requests for prior authorization medications to AmeriHealth Caritas Louisiana/PerformRx Pharmacy Services 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 LDH single PDL (PDF) for exceptions to the generic requirement.
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.
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.
Beginning April 1, 2019, through December 31, 2019, members with a household income of $800 or less per month will have a $0 drug co-pay.
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
- 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.