Effective January 1, 2023, the Louisiana Medicaid Pharmacy Program now consists of Fee for Service (FFS) Medicaid and six Managed Care Organizations (MCO). Humana Healthy Horizons® in Louisiana is the newest MCO and utilizes the same Pharmacy Benefits Manager (Gainwell Technologies) as fee-for-service (FFS) Medicaid. Please submit pharmacy claims for Medicaid recipients with coverage through Humana Healthy Horizons online at Point of Sale (POS) to Gainwell Technologies.
Humana Healthy Horizons billing information
When presented with a Humana Healthy Horizons member ID card, pharmacy staff should also request the Healthy Louisiana Medicaid ID Card.
Humana pharmacy claims must be submitted with either the legacy Louisiana Medicaid number or Card Control Number (CCN), which may be found on the Healthy Louisiana Medicaid ID Card. Humana pharmacy claims billed with the Humana “H” member ID will deny with NCPDP Reject Code 52 (Non-Matched Cardholder ID). The BIN and PCN are the same as FFS billing, but with the addition of HUMANA as a group ID. If a Humana pharmacy claim is billed without HUMANA in NCPDP field 301-C1 (Group ID), the claim will deny with EOB 367 (Group number is missing or invalid for Humana), which is mapped to NCPDP Reject Code 06.
If you have pharmacy processing issues, please call the Pharmacist Rx Inquires line at 1-800-648-0790. If you have any other questions, please call the Member Pharmacy Help Desk: 1-800-448-3810.
Pharmacy prior authorization
The process by which medication is supplied by a pharmacy and billed through the pharmacy benefit includes medication prior authorization (PA), quantity limits, and medication exceptions.
Prior authorizations are obtained through the University of Louisiana at Monroe (ULM) College of Pharmacy. Prior authorizations can be requested by phone, fax or mail:
- Phone submissions: 1-866-730-4357
- Faxed submissions: 1-866-797-2329
(Do not include a coversheet) - Mail submissions:
ULM
College of Pharmacy “Rx PA Program”
1800 Bienville Drive
Monroe, LA 71201-3765
Physician-administered drug prior authorization
About Humana Healthy Horizons in Louisiana
Humana Healthy Horizons in Louisiana members get prescription drug coverage through Gainwell, Louisiana’s Medicaid fee-for-service pharmacy benefit manager (PBM).
The Louisiana Medicaid PBM provides pharmacy benefits for all Medicaid recipients in Louisiana. The Louisiana Department of Health utilizes a single Preferred Drug List (PDL). Humana develops utilization management policies.
The PDL includes some preferred brands, as well as preferred diabetic supplies, such as blood glucose strips, lancets, meters, and syringes. The Louisiana Department of Health will notify providers if the PDL changes.
Medication on the PDL may have a small copayment for members 21 and older, based on calculated state payment(s). However, there are no copayments for medication on the PDL for the following types of members:
- Alaskan Eskimos
- Members 20 and younger
- Members receiving hospice services
- Members receiving services on the basis of breast or cervical cancer diagnoses
- Members who are inpatients in long-term care facilities or other institutions
- Native Americans
- Pregnant members
There never is a copayment for family-planning services and supplies and/or emergency services.
Medication Therapy Management
Humana offers a Medication Therapy Management (MTP) program that helps ensure your eligible patients achieve the best possible outcomes from their medications. The patient-centered MTM program promotes collaboration among the pharmacist, patient, and prescriber to optimize safe and effective medication use. The goal of this program is to optimize therapeutic outcomes by focusing on safety, effectiveness, lower-cost alternatives, and adherence.
Prescribers with questions about the program may call 1-888-210-8622 (TTY: 711), Monday – Friday, from 7 a.m. – 6 p.m.
Pharmacy lock-in program
The lock-in program is designed for individuals enrolled in Medicaid in Louisiana who need help managing their use of prescription medications. The Louisiana Department of Health requires us to use a lock-in program to help limit overuse of benefits, reduce unnecessary costs to Medicaid, and provide an appropriate level of care for our members.
Humana Healthy Horizons® in Louisiana members who meet lock-in program criteria will be locked in to using one pharmacy.
To identify members who meet lock-in program criteria, we monitor claims activity for signs of misuse or abuse in accordance with state and federal laws. If this review reveals an unusually large number of controlled-substance prescriptions or misuse of prescriptions, we will notify the member in writing of their enrollment in the lock-in program and provide the designated lock-in pharmacy’s information.
Over-the-counter health and wellness
Humana Healthy Horizons in Louisiana members have an expanded pharmacy benefit, which provides up to $25 per calendar month allowance to spend on over-the-counter (OTC) medicine, like pain relievers, diaper rash cream, cough and cold medicine, and first-aid supplies.
These items will be sent by mail within 10-14 working days of receiving a member’s order. Members do not pay shipping charges.
If you have questions about this mail-order service, call CenterWell Pharmacy™ at 1-855-211-8370 (TTY: 711), Monday – Friday, from 7 a.m. – 10 p.m., and Saturday, from 7:30 a.m. – 5:30 p.m.