Authorization process for non-formulary or restricted drugs in assisted and long-term care facilities
Guidance to providers and dispensing pharmacies serving Neighborhood Health Plan of Rhode Island members in assisted living and long-term care facilities regarding submission of drug prior authorizations when requested drugs are non-formulary, OTC non-formulary, or have utilization management restrictions.
No material clinical or coverage changes.
Policy overview
Neighborhood Health Plan of Rhode Island advises providers to use the drug formulary when creating treatment plans for members residing in assisted living and long-term care facilities. When a required medication is not included on the member's formulary, including non-formulary over-the-counter (OTC) drugs or medications that have utilization management restrictions, providers should obtain approval by submitting a drug prior authorization.
Dispensing pharmacies serving members in assisted living and long-term care facilities may request that a prior authorization be submitted to place an override and dispense medications that are non-formulary or subject to utilization management restrictions.