CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prescription Drug Coverage In Assisted Living And Long Term Care Facilities

Describes Neighborhood Health Plan of Rhode Island's expectations for prescribing/dispensing drugs for members in assisted living and long-term care facilities, referencing use of formularies and prior authorization requirements for non-formulary, OTC, or restricted medications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrescription Drug Coverage In Assisted Living And Long Term Care Facilities

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionIf a member requires a drug not on their formulary, including non-formulary OTC drugs or medications with restrictions, submit a prior authorization to Neighborhood before prescribing or dispensing.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or prior authorization requirements.

1Key Action Required

1Document Type

Policy summary

Subject: Prescription drug coverage in assisted living and long-term care facilities — Status: CURRENT.

Neighborhood Health Plan of Rhode Island is committed to ensuring members in assisted living and long-term care facilities have access to safe and cost-effective treatment options and expects provider partners to utilize Neighborhood drug formularies when creating drug treatment plans for members.

Prior authorization expectations

Prior Authorization Expectations

Providers and dispensing pharmacies should obtain prior authorization when the following apply:

ANY of the following

Non-formulary drug: Drug required is not included in the member's respective formulary (non-formulary drug).
Non-formulary OTC drug: Medication is a non-formulary over-the-counter (OTC) drug.
Utilization management restriction: Medication has a utilization management restriction (including step edits, quantity limits, or other restrictions).

ref

Actions required of providers and pharmacies

Prior Authorization

Prior authorization required for non-formulary/OTC/restricted drugs

If a member requires a drug not on their formulary, including non-formulary OTC drugs or medications with restrictions, providers must submit a prior authorization to Neighborhood before prescribing/dispensing.

Prior Authorization

Pharmacy prior authorization before override/dispense

Dispensing pharmacies servicing assisted living and long-term care members may request that a prior authorization be submitted for drugs with utilization management restrictions prior to placing an override and dispensing the medication.

Documentation Required

Use current formularies

Providers are expected to utilize Neighborhood drug formularies when creating drug treatment plans and should refer to the most up-to-date formularies on the payer website.

Who this applies to

Prescription drug coverage — assisted living and long-term care

PopulationPrescription drug coverage for members in assisted living and long-term care facilities

SettingAssisted living and long-term care facilities

Applies toProviders and dispensing pharmacies

Policy stanceinformational

Key expectationsProviders should use Neighborhood formularies and submit prior authorization when drugs are non-formulary, OTC non-formulary, or have utilization management restrictions; pharmacies may request prior authorization before override/dispense

Payer intent and formulary guidance

Neighborhood affirms its commitment to safe, cost-effective treatment and expects providers to follow Neighborhood formularies when developing treatment plans; providers should consult the most up-to-date formularies listed by line of business on the payer website.

If a member requires a drug not on their formulary, including non-formulary OTC drugs or medications with utilization management restrictions, providers must submit a prior authorization to Neighborhood, and dispensing pharmacies may request prior authorization before placing an override and dispensing.