CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Formulary Exception / Prior Authorization Request Form

A pharmacy prior authorization/formulary exception request form for providers to submit clinical information to Neighborhood Health Plan of Rhode Island to obtain coverage decisions for non-formulary or restricted medications, including expedited decision option and required documentation fields.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFormulary Exception / Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProviders must complete and fax the Formulary Exception Prior Authorization Form with all required clinical information and documentation to Neighborhood at 1-866-423-0945 or use Cover My Meds for real-time coverage determination.

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief.

1Form used for prior authorization requests

24Expedited decision timeframe (hours)

Policy Snapshot

This form standardizes requests to Neighborhood Health Plan of Rhode Island for formulary exceptions and prior authorizations, capturing key patient, prescriber, diagnosis and medication details and clinical justification, including enrollee name/member ID, medication strength/route/frequency, start date, quantity, and allergies. It references compendia-supported indications and dosing (examples: AHFS and Micromedex) and requires documentation of trials or contraindications to formulary alternatives (including names of medications tried and reasons for failure). An expedited decision option is available when waiting could seriously harm the enrollee, with a checkbox to request a decision within 24 hours, and the form includes fields for required documentation such as dosing, start date/response for continuation, and rationale for medical necessity.

What Providers Must Do

Prior Authorization

Submit Formulary Exception / Prior Authorization

Providers must complete and fax the completed Formulary Exception Prior Authorization Form with all required clinical information and documentation to Neighborhood at 1-866-423-0945. For real-time coverage determinations, providers may use Cover My Meds.

Fax: 1-866-423-0945
Cover My Meds option for real-time coverage determination

Documentation Required

Required Clinical Documentation

Required clinical documentation includes the diagnosis, prescribed dosing, documentation of prior trials of formulary alternatives (medication names and reasons for failure), any contraindications or intolerances to alternatives, start date and response for continuation requests, and an explanation of the medical necessity/rationale for the requested drug.

Diagnosis
Dosing (dose the member will be taking)
Prior trials of formulary alternatives — medication names and reasons for failure
Contraindications/intolerances to alternatives
Start date and response when request is for continuation of therapy
Rationale for medical necessity

Prior Authorization

Expedited Decision Request

If the prescriber believes that waiting could seriously harm the member's life, health, or ability to regain maximum function, the prescriber must check the expedited box on the form to request a decision within 24 hours.

Check the expedited box to request a decision within 24 hours if waiting could seriously harm the member

Documentation Required

Combination/Generic/Dosage Form Requirements

When requesting a combination product, a brand product when a formulary generic exists, or an alternative dosage form, provide documentation showing that the separate components, the formulary generic, or the alternative dosage form cannot be taken, plus documentation of the remaining required number of formulary alternatives.

For combination products: evidence individual components cannot be taken PLUS remaining required alternatives
For brand when generic exists: evidence the formulary generic cannot be taken PLUS remaining required alternatives
For alternative dosage forms: evidence the alternative form cannot be taken PLUS remaining required alternatives (only if clinically appropriate)

Scope and Applicability

This is a pharmacy prior authorization/formulary exception request form for providers to submit clinical information to Neighborhood Health Plan of Rhode Island to obtain coverage decisions for non-formulary or restricted medications. Providers must complete the form and provide clinical details (diagnosis, medication, dose, start date, response), document trials or inability to take formulary alternatives (medication names and reasons for failure), and may request an expedited decision within 24 hours if waiting could seriously harm the enrollee.

Intended audiencePrescribers / Pharmacy prior auth teams

Use caseFormulary exceptions and prior authorizations for non-formulary or restricted meds

Expedited criteriaSerious harm - decision within 24 hours

Submission methodsFax 1-866-423-0945; Cover My Meds

Clinical References and Form Guidance

The form emphasizes use of compendia-supported indications and dosing (examples: AHFS, Micromedex) and requires documentation that the patient has tried and failed the required number of formulary alternatives (typically 2 in a class with 2+ alternatives or 1 if only 1 alternative), or documentation of intolerance/contraindication if alternatives cannot be taken. It also requires that prescribed dosing/quantity align with FDA-approved labeling or compendia-supported dosing and that, for combination products, brand versus generic, or alternative dosage forms, documentation shows individual components, the formulary generic, or the alternative dosage form are unable to be taken plus remaining required alternatives.