Certain formulary medications and all non-formulary medications require a written Prior Authorization (PA) request to be submitted by the prescribing practitioner for our L.A. Care members.
Each PA request will be reviewed based on the individual member's need. Determination will be based on documentation of existing medical need.
Generic Substitution
L.A. Care has a mandatory generic program. The intent of this program is to promote utilization of appropriate generic alternatives as first line therapies when medically appropriate.
If a member or physician requests a brand name product in lieu of an approved generic due to documented medical need, a written request for coverage using the Prior Authorization Form must be submitted. Procedures and timeframes will follow our Prior Authorization process.
Step Therapy
L.A. Care uses Step Therapy to promote cost-effective pharmaceutical management when there are multiple effective drugs to treat a medical condition.
Drugs that have a step therapy requirement will require one or more "prerequisite" first step drugs to be tried before progressing to the second step drug. When a prescription for a Step Therapy drug is filled at the dispensing pharmacy, the pharmacy benefits claims processor will search past claims for the first step drugs.
A Step Therapy drug can be obtained without first trying a first step drug by submitting a Prior Authorization Form with documentation of existing medical need for consideration. Procedures and timeframes will follow our Prior Authorization process.
Quantity Limits
L.A. Care has identified a select number of medications to be subjected to quantity limits. A quantity limit establishes the maximum amount of medication that L.A. Care will cover within a defined period of time.
If a member has a medical condition that requires a quantity of medication exceeding our limit, a written request using our Prior Authorization Form, along with documentation of an existing medical need, must be submitted for consideration. Procedures and timeframes will follow our Prior Authorization process.
Therapeutic Interchange
L.A. Care may use Therapeutic Interchange to promote clinical practice guidelines when evidence suggests outcomes can be improved by substituting a drug that is therapeutically equivalent but chemically different from the prescribed drug.
Therapeutic Interchange protocols are never automatic; a dispensing provider can not substitute a therapeutically equivalent alternative drug for the prescribed drug without the knowledge and authorization of the prescribing practitioner.