CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Neighborhood Health Plan of Rhode Island Commercial Drug Formulary

Defines the outpatient pharmacy formulary for Neighborhood Health Plan of Rhode Island Commercial members, including formulary development criteria, coverage limitations, prior authorization, step therapy, exception and adverse determination processes, and communication channels. Applies to outpatient drugs only and excludes inpatient medications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNeighborhood Health Plan of Rhode Island Commercial Drug Formulary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionPrescriber or representative must fax a completed PA request to 1-866-423-0945 or call Neighborhood Pharmacy Department at 1-401-427-8200; requests reviewed per PBM P&T Committee criteria.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

5Formulary Decision Criteria Listed

3Non-Covered Categories

4Administrative Processes

Coverage Summary

Defines the outpatient pharmacy formulary for Neighborhood Health Plan of Rhode Island Commercial members, including how the Formulary is developed and updated by the Pharmacy & Therapeutics Committee, coverage limitations (outpatient only; inpatient medications are excluded), and administrative processes such as prior authorization, step therapy, exception and adverse determination procedures.

Formulary Criteria and Administrative Requirements

General Formulary Coverage Principles

Formulary applies when ALL of the following are met:

ALL of the following

Formulary inclusion: Drug is listed on the Neighborhood Formulary (outpatient pharmacy benefit).
Non-excluded use: Drug is not excluded as experimental, cosmetic, or otherwise non-covered per policy.
Generic substitution: FDA-approved generic substitutions to be used when available.

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Coverage Limitations / Non-Covered

Drugs are not covered when ANY of the following apply:

ANY of the following

Cosmetic use: Drug product is used for cosmetic purposes.
Experimental or off-label: Drug product is experimental or used in an experimental or off-label manner (as determined by PBM P&T Committee).
Safety screens: Drug product fails industry-standard patient safety screens without further prescriber information.

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Prior Authorization (PA) Requirement

Covered when ALL of the following are met for PA-listed drugs:

ALL of the following

Submit PA: Prescriber or representative submits a completed Prior Authorization Request to Neighborhood Pharmacy Department via fax (1-866-423-0945) or contacts pharmacist at 1-401-427-8200.
Review criteria: Each PA request will be reviewed on individual patient need and according to PBM P&T Committee–approved criteria.

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Step Therapy (ST) Requirement

Drugs listed as ST are covered when ONE of the following is met:

ANY of the following

Trial and failure: Member has tried and failed the required formulary products specified by step therapy.
Exception to step therapy: Provider obtains an exception to step therapy by documenting why required formulary alternatives are inappropriate or cannot be taken by the member.

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Exception Process for Non-Formulary Medications

Coverage for non-formulary medications requires meeting ANY of the following:

ANY of the following

Contraindication documented: Use of formulary product is contraindicated in the patient (prescriber documents contraindication).
Prior failure documented: Patient has failed an appropriate trial of formulary or related agents (prescriber documents failure).
Clinical risk documented: Use of a formulary drug may provoke an underlying condition detrimental to patient care (prescriber documents clinical risk).
Safety justification: Choices in the Drug Formulary are not suited for the present patient care need and the selected drug is required for patient safety (prescriber documents justification).

Adverse Determination / Denial Process

When a request does not meet exception or PA criteria, the following process applies:

ALL of the following

Medical Director review: Prescriber will be referred to the Neighborhood Medical Director or Physician Reviewer to assess medical necessity.
Written notification on denial: If denied, written notification will be provided to prescriber and member documenting reasons, applicable benefits or clinical guidelines, and appeal rights.
Discussion of denial: Medical Director or Physician Reviewer will discuss denial rationale and appeals process with prescribing practitioner.
Member inquiries: Members may file inquiries or complaints with Customer Service and will be informed of appeal rights.

Actions Required by Providers

Prior Authorization

Submit Prior Authorization for PA-listed drugs

Prescriber or representative must fax a completed PA request to 1-866-423-0945 or call Neighborhood Pharmacy Department at 1-401-427-8200; requests reviewed per PBM P&T Committee criteria.

Fax: 1-866-423-0945
Phone: 1-401-427-8200
Code: PA (Prior Authorization required)

Step Therapy

Document trials for Step Therapy

If drug is ST-listed, provider must document trial and failure of required formulary alternatives or request an exception with justification.

Code: ST (Step Therapy required) - document trials and failures or submit exception

Documentation Required

Exception supporting documentation

When requesting non-formulary coverage, prescriber must provide documentation of contraindication, prior failures, clinical risk, or safety justification to support exception.

Documentation of contraindication
Documentation of prior failures of formulary agents
Documentation of clinical risk that would be provoked by formulary drugs
Documentation of patient safety justification

Denial Risk

Denial and appeal notification

If request is denied, Medical Director/Physician Reviewer will send written notice to prescriber and member with rationale, applicable guidelines, and appeal instructions; the reviewer will discuss the denial rationale and appeals process with the prescribing practitioner and members may contact Customer Service for inquiries.

Definitions and Background

Formulary: List of medications covered under the outpatient pharmacy benefit for Neighborhood Health Plan of Rhode Island Commercial members.

Therapeutic Interchange: Replacing, with the prescribing physician's approval, a prescription medication with a chemically different medication expected to produce similar clinical effectiveness.

Prior Authorization (PA): Process requiring approval before coverage is granted for certain drugs; prescribers or their representatives must fax a completed PA request to 1-866-423-0945 or call 1-401-427-8200 and requests are reviewed per PBM P&T Committee criteria.

Step Therapy (ST): Requirement that members try specified formulary products before initiating the requested medication unless an exception is granted; providers may request an exception when formulary alternatives are inappropriate or cannot be taken by the member.

The P&T Committee meets at least quarterly to review and update the dynamic Formulary; decisions consider safety, efficacy, effectiveness, duplication, and cost-effectiveness, and the Formulary is adjusted accordingly to promote generic substitution and therapeutic interchange when appropriate.

PA	Prior Authorization required
QL	Quantity Limit
ST	Step Therapy required
OTC	Over The Counter product
C	Can be dispensed at retail pharmacy up to 365 days' supply in one fill

OpenPayer

Neighborhood Health Plan of Rhode Island Commercial Drug Formulary

Coverage Summary

Formulary Criteria and Administrative Requirements

Actions Required by Providers

Formulary Identifiers and Restrictions

Definitions and Background