CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Point-of-sale pharmacy discount card pricing for Commercial members

Describes a Pharmacy Department initiative that at point-of-sale compares contracted insurance pricing to discount card pricing and uses the lower price for Neighborhood Health Plan of Rhode Island Commercial plan members; does not apply to Medicaid or INTEGRITY (MMP) plans.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPoint-of-sale pharmacy discount card pricing for Commercial members

Policy CodePolicy N/A

Change TypeOperational initiative (no material coverage change)

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionAt point of sale the Pharmacy Benefit Manager compares contracted insurance rate to a discount card price and, if the discount card is less expensive, processes the claim using the discount card pricing so the member benefits from a lower cost share.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2024-01-01initiative start

Commercialapplicability

Medicaid + INTEGRITYexclusions

point-of-salelocation

Point-of-sale Discount Card Processing Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPoint-of-sale pharmacy discount card pricing for Commercial members

Policy CodePolicy N/A

Change TypeOperational initiative (no material coverage change)

Effective DateJan 1, 2024

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Point-of-sale discount card processing criteria

Operational criteria for applying discount card pricing at point-of-sale:

Member is enrolled in a Neighborhood Health Plan of Rhode Island Commercial plan (program applies exclusively to Commercial members).

At point of sale the Pharmacy Benefit Manager compares the contracted insurance rate to a discount card price for the prescribed product.

If the discount card price is lower than the contracted insurance rate, process the claim using the discount card pricing so the member benefits from a lower cost share.

Program does not apply to Medicaid or INTEGRITY (MMP) plan members.

Pharmacy Point-of-Sale Comparison and Processing

Billing Rule

Compare contracted rate to discount card and use lower price at point-of-sale

At the point of sale, the Pharmacy Benefit Manager must compare the contracted insurance rate to the discount card price and, if the discount card price is lower, process the claim using the discount card pricing so the member receives the lower cost share.

Applies only to Neighborhood Commercial plan members.
Does not apply to Medicaid or INTEGRITY (MMP) plan members.

Applicable Members and Exclusions

Commercial plan members — definition and applicability

DefinitionCommercial plan members are members enrolled in Neighborhood Health Plan of Rhode Island's Commercial plans.

Program applicabilityThe point-of-sale discount card initiative applies exclusively to Neighborhood Health Plan of Rhode Island Commercial plan members.

Operational effectIf a discount card price is lower than the contracted insurance rate at point-of-sale, the claim will be processed using the discount card pricing so the member benefits from a lower cost share.

Implementation start dateEffective January 1, 2024 — initiative introduced by the Pharmacy Department via the Pharmacy Benefit Manager.

Exclusions — plans not included in this initiative

Excluded plan typesMedicaid plans are excluded from this initiative.

Excluded plan types 2INTEGRITY (MMP) plans are excluded from this initiative.

Scope noteThe program does not extend to Medicaid or INTEGRITY (MMP) plan members; it applies only to Commercial members at point-of-sale.