CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior Authorization expectations for drugs in assisted and long-term care facilities

Notification to providers and dispensing pharmacies that Neighborhood expects use of its drug formularies for members in assisted and long-term care facilities and requires prior authorization for non-formulary, OTC, or restricted medications. Provides link guidance to current formularies.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior Authorization expectations for drugs in assisted and long-term care facilities

Policy CodePolicy N/A

Change TypeInformational

Effective DateApr 1, 2023

Next Review Date

Key ActionSubmit a Prior Authorization request to Neighborhood when a member requires a non-formulary, OTC, or restricted medication.

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy — brief provides administrative expectations only.

1Prior Authorization required

CURRENTStatus

Policy overview

Subject: Prior Authorization expectations for drugs in assisted and long-term care facilities

Status: CURRENT

Effective date: 2023-04-01

Neighborhood Health Plan of Rhode Island communicates expectations to ensure members in assisted and long-term care facilities receive safe and cost-effective treatments by aligning provider prescribing with plan formularies and utilization management processes.

Who and what this applies to

Notification to providers and dispensing pharmacies that Neighborhood expects use of its drug formularies for members in assisted and long-term care facilities and requires Prior Authorization for non-formulary, over-the-counter (OTC), or restricted medications.

The most up-to-date versions of Neighborhood formularies are listed by line of business on Neighborhood's website.

Effective Date2023-04-01

Last Review

Next Review

Coverage stanceinformational

Required provider actions and documentation

Prior Authorization

Prior authorization required for non-formulary / restricted drugs

Providers must submit a Prior Authorization request to Neighborhood when a member requires a drug that is not on their respective formulary, including non-formulary OTC medications or medications that have a restriction. Dispensing pharmacies for assisted and long-term care facilities may request that providers submit a Prior Authorization to obtain an override and dispense the medication.

affects: non-formulary, OTC, restricted drugs

Documentation Required

Use Neighborhood formularies when creating drug treatment plans

Providers are expected to utilize Neighborhood drug formularies when creating drug treatment plans for members residing in assisted and long-term care facilities; the most up-to-date formularies are available on Neighborhood's website by line of business.

link to formularies on payer website