Bienville Building ▪ 628 N. Fourth St. ▪ P.O. Box 91030 ▪ Baton Rouge, Louisiana 70821-9030
Phone: (888) 342-6207 ▪ Fax: (225) 342-9508 ▪ www.ldh.la.gov
An Equal Opportunity Employer
M E M O R A N D U M
DATE: May 15, 2024
TO: All Louisiana Medicaid Prescribing Providers and Pharmacists
FROM: Kimberly Sullivan, Medicaid Executive Director
SUBJECT: Louisiana Medicaid Pharmacy Single Preferred Drug List (PDL)
Update – Effective July 1, 2024
Effective July 1, 2024, the Louisiana Medicaid Pharmacy Program is implementing
changes to the Single Preferred Drug List (PDL). The Single PDL updates apply to
pharmacy claims submitted to Gainwell for FFS and to Magellan for MCOs (Aetna,
AmeriHealth Caritas, Healthy Blue, Humana Healthy Horizons, Louisiana Healthcare
Connections, and UnitedHealthcare).
The current PDL indicated a preference of some brand name drugs over generic drugs.
The revised PDL will shift both brand and generic versions of these drugs to preferred
status. With the implementation of the new PDL, prescribing providers are advised to
note “brand name necessary” on any prescription where they want to ensure pharmacies
fill their prescriptions with a brand name drug. If this notation is absent, individual
pharmacists will make the decision on whether to fill the prescription with brand
or generic drugs.
Pharmacies are advised to begin preparing for the July PDL implementation now
with any necessary inventory adjustments.
The new PDL will be posted online when implemented on July 1, 2024 at
https://ldh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf. The following chart list all drugs
that will transition to brand and generic preferred with the exception of Revatio
Suspension, which will be generic preferred and brand non-preferred.
Jeff Landry
GOVERNOR
Ralph L. Abraham, M.D.
SECRETARY
State of Louisiana
Louisiana Department of Health
Bureau of Health Services Financing
LA Medicaid Pharmacy Single PDL Update
May 15, 2024
Page 2
Brand Name
Therapeutic Class
Starting July 1, 2024
Adderall XR
ADD/ADHD: Stimulants and
Related Agents
Brand and Generic Preferred
Advair Diskus
ASTHMA/COPD:
Glucocorticoids, Inhalation
Brand and Generic Preferred
Advair HFA
ASTHMA/COPD:
Glucocorticoids, Inhalation
Brand and Generic Preferred
Alphagan P 0.15%
Glaucoma agents: intraocular
pressure (IOP) reducers
Brand and Generic Preferred
Amitiza
GI motility, chronic
Brand and Generic Preferred
Apriso
Digestive disorders: ulcerative
colitis agents
Brand and Generic Preferred
Banzel Tablet and Suspension
Anticonvulsants
Brand and Generic Preferred
Bethkis
Infectious disorders: inhaled antibiotics
Brand and Generic Preferred
Carbatrol
Anticonvulsants
Brand and Generic Preferred
Combigan
Glaucoma agents: intraocular
pressure (IOP) reducers
Brand and Generic Preferred
Copaxone 20 MG/ML
Multiple sclerosis:
immunomodulatory agents
Brand and Generic Preferred
Copaxone 40 MG/ML
Multiple sclerosis:
immunomodulatory agents
Brand and Generic Preferred
Depakote Sprinkle
Anticonvulsants
Brand and Generic Preferred
Elidel
Dermatology: atopic dermatitis
immunomodulators
Brand and Generic Preferred
Natroba
Dermatology: antiparasitic
agents, topical
Brand and Generic Preferred
Nexium Suspension
Digestive disorders: proton
pump inhibitors
Brand and Generic Preferred
Pradaxa
Anticoagulants
Brand and Generic Preferred
Protonix Suspension
Digestive disorders: proton
pump inhibitors
Brand and Generic Preferred
Renvela Tablet
Hemodialysis: phosphate binders
Brand and Generic Preferred
Restasis
Ophthalmic disorders: antiinflammatory/
immunomodulators
Brand and Generic Preferred
Retin-A Cream
Acne agents, topical
Brand and Generic Preferred
Revatio Suspension
Heart disease, hyperlipidemia:
pulmonary arterial hypertension (PAH)
Brand non-preferred
Generic preferred
Revlimid
Oncology: oral – hematologic
Brand and Generic Preferred
LA Medicaid Pharmacy Single PDL Update
May 15, 2024
Page 3
Brand Name
Therapeutic Class
Starting July 1, 2024
Sabril Tablet and Powder
Pack
Anticonvulsants
Brand and Generic Preferred
Spiriva HFA
Asthma/COPD: bronchodilator,
anticholinergics inhalation
Brand and Generic Preferred
Suboxone Film
Opiate dependence agents
Brand and Generic Preferred
Symbicort
Asthma/COPD: glucocorticoids,
inhalation
Brand and Generic Preferred
Tegretol XR
Anticonvulsants
Brand and Generic Preferred
Trileptal Suspension
Anticonvulsants
Brand and Generic Preferred
Trokendi XR
Anticonvulsants
Brand and Generic Preferred
Ventolin HFA
(other generic albuterol
inhalers will remain preferred
Asthma/COPD: bronchodilator,
beta-adrenergic inhalation
Brand and Generic Preferred
Additional Information:
Refer to http://ldh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf for the PDL, which is
inclusive of the Louisiana Uniform Prescription Drug Prior Authorization Form,
medication list, and criteria.
If you have questions about the content of this memo, you may contact the FFS pharmacy
help desk by phone at (800) 437-9101.
FFS pharmacy claims should be submitted to Gainwell Technologies. MCO pharmacy
claims should be submitted to Magellan.
If you have questions about pharmacy claims billing, you may contact the appropriate
plan at their pharmacy help desk listed in the chart below.
Healthcare Provider
Pharmacy Help Desk
Pharmacy Help Desk
Phone Number
Aetna, AmeriHealth Caritas,
Healthy Blue, Humana Healthy
Horizons, Louisiana Healthcare
Connections, UnitedHealthcare
Magellan
(800) 424-1664
Fee for Service
Gainwell Technologies
(800) 648-0790
LA Medicaid Pharmacy Single PDL Update
May 15, 2024
Page 4
Please forward this notice to other providers to assist with notification. Your continued
cooperation and support of the Louisiana Medicaid Program efforts to coordinate care
and improve health are greatly appreciated.
KS/MBW/GJS
c: Healthy Louisiana Plans
Melwyn B. Wendt
Gainwell Technologies
Magellan