Louisiana program
A $150 cap for certain specialty medicines
Louisiana caps some prescription charges when a health plan places a medicine in its highest-cost specialty category.
What it is
Louisiana caps some prescription charges when a health plan places a medicine in its highest-cost specialty category.
A specialty medicine can bring a large pharmacy bill even with insurance. Louisiana’s cap applies only to eligible plans and medicines in the specified specialty category. The deductible must be met before the cap starts.
Eligibility rules
- The plan must cover prescriptions and use a tier above preferred or nonpreferred brand drugs.
- The $150 limit applies per qualifying drug for up to a 30-day supply after the deductible and until the out-of-pocket maximum is reached. R.S. 22:1060.5 took effect January 1, 2015. A private employer’s self-funded ERISA plan is generally outside the state mandate; other self-funded arrangements need their own scope check.
What you get
- At most $150 per eligible specialty drug per month for up to a 30-day supply after the deductible.
What the help covers
- The cap applies per medicine. Two qualifying medicines can each have a separate charge.
- A separate law generally counts cost-sharing payments made on your behalf, subject to an HSA qualification.
- A separate Louisiana rule makes a drug maker’s copay card or a charity’s payment count toward your deductible and yearly limit on most plans, including the state employee plan. If the credit is missing from a statement, ask the plan why.
If you decide to apply
- Ask the insurer which prescription cost category it assigned to the medicine and whether the Louisiana cap applies.
- Have the pharmacy receipt, insurance explanation and any manufacturer assistance information ready.
The plan; the Department of Insurance on complaint: 800-259-5300
After you apply
- The plan can explain its calculation and review an amount charged above an applicable cap.
Good to know
The Office of Group Benefits state employee plan is excluded from this cap. Its inclusion in other cancer laws does not change that.
Other details
- The Department of Insurance can help with a state-regulated plan question at 800-259-5300.
Official sources
“Does the $150 specialty-drug cap apply to any of my child’s medicines? Could you explain the exclusions and help request a corrected claim if it does?”
Why I’m asking: I want to understand both the medicine’s cost category and how outside payment assistance is counted.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask which tier the drug is on, and keep the pharmacy receipts.
Your social worker
The pharmacy team can tell you how the claim was processed.
The care team
Records and letters when the application asks for them.
- Who decides
- The plan; the Department of Insurance enforces on insured plans.
- Ask HR
- “Is this drug on a specialty tier, and is our plan insured? Louisiana caps specialty cost sharing at $150 per drug a month after the deductible.”
How to apply
First step: Ask the plan in writing which tier the drug sits on and whether the Louisiana specialty cap has been applied.
- Ask the plan in writing which tier the drug sits on.
- If this plan and drug qualify and the deductible is met, ask for the cap and a review of any overcharge.
- If someone pays on your behalf, ask whether those payments count under the separate payment-credit rule and whether an HSA tax-qualification exception applies.
Where it starts: Ask the plan to confirm statutory scope, the drug’s tier and deductible status before requesting the cap or a correction.
What to gather
- The pharmacy receipt or explanation of benefits
- The plan's formulary tier for that drug
- Any manufacturer card you are using
How long: The plan confirms when a claim correction takes effect and whether earlier eligible claims can be adjusted.
What a yes looks like
A fill that costs no more than $150, and a refund of anything overcharged.
What a no looks like, and the next move
Ask for the specific plan or drug exclusion in writing. OGB’s cap exclusion does not remove its separate payment-credit protection. Private ERISA funding requires a separate scope review.
Watch out
- The cap starts after the deductible, so an early-year bill can still be large.
- The state employee plan is expressly outside this cap, even though other Louisiana cancer rules do reach it.
- The drug has to be on a specialty tier. Ask the plan which tier it used.
If they say no, quote this: R.S. 22:1060.5 limits specialty-tier copayment or coinsurance to $150 per drug per month for up to a thirty-day supply, after the deductible.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
For a plan subject to R.S. 22:1060.5, a qualifying specialty-tier drug is capped at $150 per drug per month for up to a 30-day supply after the deductible. The Office of Group Benefits is excluded from that cap, but included in the separate third-party payment-credit rule.
- $150/month — Maximum cost sharing per specialty drug per month, after the deductible
- $30 — Days of supply the cap covers
Legal protection: Copayment or coinsurance limited to $150 per specialty-tier drug per month for up to a thirty-day supply, after the deductible and until the out-of-pocket maximum · Cost-sharing amounts paid on the enrollee's behalf by another person generally count towards the enrollee's own cost sharing
What it costs the family: At most $150 a month per specialty drug once the deductible is met, on a plan the cap reaches.
The eligibility facts, as published
- Plans
- Louisiana health benefit plans that cover prescription drugs and use a tier above preferred or non-preferred brand
- Excluded
- the Office of Group Benefits and its claims administered by insurers, for the $150 cap
- Timing
- the cap applies after any deductible and until the out-of-pocket maximum is reached
- Statute refs
- R.S. 22:1060.5; R.S. 22:976.1
The trap: The cap starts after the deductible, so a January bill can still be large. And the drug has to actually sit on a specialty tier: ask the plan which tier it used.
Where I read this
- Louisiana Revised Statutes 22:1060.5 (specialty-tier cost sharing) — Louisiana Legislature, read September 10, 2026
- Louisiana Revised Statutes 22:976.1 (third-party cost-sharing credit) — Louisiana Legislature, read September 10, 2026