CurrentNeighborhood Health Plan of Rhode IslandPolicy 000826

Policy_Benefit Exclusion_Final_8.21.24_Db 1

Defines medications, medication classes, and related products that are benefit exclusions (not covered) across Neighborhood's Medicaid, Commercial, and INTEGRITY (Medicare-Medicaid Plan) benefits. Lists specific excluded categories and notes references to member materials and contracts.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPolicy_Benefit Exclusion_Final_8.21.24_Db 1

Policy CodePolicy 000826

Change TypeRevision (08/21/2024) — no material clinical changes indicated

Effective DateJul 26, 2019

Next Review Date

Key ActionConfirm OTC drugs/products are listed on the plan formulary at www.nhpri.org before relying on coverage.

SourceLink

POLICY UPDATE CHANGES

Policy review and revision occurred on 08/21/2024.

3Benefit scopes listed (Medicaid, Commercial, INTEGRITY)

17Medicaid exclusion examples

12Commercial exclusion examples

Coverage Summary

Scope: Defines medications, medication classes, and related products that are benefit exclusions (not covered) across Neighborhood's Medicaid, Commercial, and INTEGRITY (Medicare‑Medicaid Plan) benefits. Coverage stance: not_covered_cosmetic. Policy subject: Pharmacy Benefit Exclusions (Neighborhood Health Plan of Rhode Island). Policy number: 000826. Effective date: 07/26/2019. Last review/revision date: 08/21/2024.

Benefit scopes listed3

Example exclusion categories listed (Medicaid list count)17

Example exclusion categories listed (Commercial list count)12

Benefit Exclusions (Not Covered)

Medicaid Benefit Exclusions (Not Covered)

The following are considered Benefit Exclusions and are therefore not covered by Neighborhood's Medicaid Benefit:

Medicaid exclusions

Biological products for allergy immunizations
Biological products for vaccinations
Blood fractions
Compound medications that are not made up of at least one legend drug
Drugs prescribed or dispensed outside of Health Plan dispensing guidelines
Drugs that have not been proven effective according to the FDA
Drugs used for cosmetic purposes
Drugs or products whose manufacturer does not participate in the Medicaid Drug Rebate Program (MDRP) (i.e., manufacturer does not have a signed National Drug Rebate Agreement on file with the Secretary of HHS)
Experimental drugs (including those placed on notice of opportunity hearing status by the Federal Drug Efficacy Study Implementation [DESI])
Medications an enrollee may take or was given while residing in an institution that provides prescription drugs as part of its services or which operates its own facility for dispensing prescription drugs
Non-medical substances (regardless of reason prescribed, intended use, or medical necessity)
Off-label use of drugs, unless mandated by laws pertaining to the treatment of cancer
Support garments and other durable medical equipment (except for diabetic testing supplies)
Therapeutic devices and appliances, including hypodermic needles and syringes (except when used to administer insulin or for self-administration of FDA-approved injectable drugs)
Medications prescribed for the treatment of sexual or erectile dysfunction (ED)
Medical marijuana
Medications for infertility treatment

Commercial Benefit Exclusions (Not Covered)

The following are considered Benefit Exclusions and are therefore not covered by Neighborhood's Commercial Benefit:

Commercial exclusions

Any drug product used for cosmetic purposes
Experimental drug products, off-label use of drug products, or any drug product used in an experimental manner are not covered, unless mandated by laws pertaining to the treatment of cancer
Medications prescribed for sexual and erectile dysfunction (ED)
Medical marijuana
Compounded products that are not made up of at least one legend drug

INTEGRITY (Medicare-Medicaid Plan) Benefit Exclusions (Not Covered)

The following are considered Benefit Exclusions and therefore not covered by Neighborhood's INTEGRITY benefit:

INTEGRITY exclusions

Medications used for sexual or erectile dysfunction
Medications used for the treatment of infertility
Medications being used for indications that are not FDA-approved or compendia-supported
Medications being used in a manner inconsistent with the requirements of a National or Local Coverage Determination, if such a policy or article exists for said medication

Provider Actions & Operational Rules

Documentation Required

Formulary/OTC exception documentation

OTC drugs/products are not covered unless listed on the plan formulary on the plan website (www.nhpri.org); providers must confirm formulary listing for OTC coverage.

Billing Rule

Network pharmacy requirement (Commercial)

Commercial prescriptions must be filled at Neighborhood network retail pharmacies to be covered except for emergency care; claims filled outside the network may be denied.

Documentation Required

Manufacturer MDRP participation requirement (Medicaid)

Medicaid will not cover drugs whose manufacturer does not participate in the Medicaid Drug Rebate Program; providers should verify manufacturer MDRP status.

Policy Identifiers & Codes

Policy Identifiersmixed

000826

Policy Number (header)

Background

This policy provides notice and context for medications and product classes excluded from Neighborhood's pharmacy benefits and specifies which medications and medication classes are considered Benefit Exclusions (not covered).

Exclusions are also communicated to members via the Medicaid Member Handbook and the Commercial Certificate of Coverage (COC), and to providers via the Provider Manual; these references are updated annually and aligned with state and federal contract obligations.

Revision History

08/21/2024revisionLatest

Policy review and revision occurred on 08/21/2024. Document shows Review Date and Revision Date of 08/21/2024 but does not state clinical policy changes. is_material: false

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPolicy_Benefit Exclusion_Final_8.21.24_Db 1

Policy CodePolicy 000826

Change TypeRevision (08/21/2024) — no material clinical changes indicated

Effective DateJul 26, 2019

Next Review Date

Key ActionConfirm OTC drugs/products are listed on the plan formulary at www.nhpri.org before relying on coverage.

SourceLink

On This Page

Prescription and OTC homeopathic drugs

Non-drug products such as therapeutic or other prosthetic devices, appliances, supports, or other non-medical products (except diabetic testing supplies)

Drugs that cannot be marketed lawfully without FDA approval and such approval has not been granted at the time of use or proposed use or such approval has been withdrawn

Prescriptions filled at pharmacies other than Neighborhood network retail pharmacies, except for emergency care

Prescription drugs once the same active ingredient or a modified version of an active ingredient is available over-the-counter

Prescription drugs when packaged with non-prescription products

OTC drugs/products are not covered unless they are listed on our formulary on our website at www.nhpri.org