CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Neighborhood Health Plan of Rhode Island Formulary (Exchange)

Defines the outpatient pharmacy formulary for Neighborhood Health Plan of Rhode Island Exchange benefit, including principles for inclusion, prior authorization, step therapy, exception process, coverage limitations, therapeutic interchange, and communication/appeals processes. Applies to outpatient prescription drugs only; inpatient medications excluded.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNeighborhood Health Plan of Rhode Island Formulary (Exchange)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionFax a completed Prior Authorization Request to Neighborhood Pharmacy Department at 1-866-423-0945 or contact Neighborhood Pharmacy Department at 1-401-459-6020 and provide clinical information demonstrating criteria for an exception.

POLICY UPDATE CHANGES

No material clinical or coverage changes

Outpatient-onlyBenefit applicability

PA/QL/STRestriction mechanisms

QuarterlyP&T Committee frequency

Coverage Summary & Scope

Coverage is for outpatient prescription drugs only: the Neighborhood Formulary lists medications covered under the outpatient (Exchange) pharmacy benefit and is available online. Coverage of listed drugs may be subject to specific restrictions and controls including Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), and limited coverage of certain Over The Counter (OTC) products when a written prescription is provided.

Formulary Coverage Criteria

General Formulary Coverage Principles

Covered outpatient drugs are those listed in the Neighborhood Formulary available online; coverage may be subject to specific restrictions such as PA, QL, ST and exclusions listed below.

ALL of the following

Drug must be listed in the Neighborhood Formulary (available at WWWnhpriorg) to be covered for outpatient benefit
FDA-approved generic substitutes are to be used when available
Drugs listed with 'PA' require prior authorization before coverage
Drugs listed with 'QL' have quantity limits
Drugs listed with 'ST' require step therapy (member must try specified formulary alternatives first unless exception granted)
Some OTC products are covered when a written prescription is provided

Prior Authorization / Exception Process

Coverage for non-formulary or PA medications may be granted via an exception process when criteria are met:

ALL of the following

Prescriber must request PA by faxing a completed Prior Authorization Request to Neighborhood Pharmacy Department at 1-866-423-0945 or contacting 1-401-459-6020
Approval may be granted when any of the following are true
- Use of Formulary products is contraindicated in the patient
- Patient has failed an appropriate trial of formulary or related agents
- Use of a Formulary drug may provoke an underlying condition detrimental to patient care

Step Therapy Exception

Step therapy requirements can be bypassed via exception if formulary alternatives are inappropriate or cannot be taken by the member:

ALL of the following

If required formulary products are not appropriate for the member or member cannot take the alternatives, provider can request an exception to Step Therapy

Adverse Determination and Appeals

Process when a request does not meet criteria:

ALL of the following

Prescriber will be referred to Medical Director or Physician Reviewer for discussion and determination of medical necessity
Rationale and formulary alternatives will be provided to the prescribing provider
In event of denial, Medical Director/Physician Reviewer will discuss reason for denial and explain appeals process
Written letters to member will document reasons, applicable benefit or clinical guideline, and appeals process; prescriber/member can review documentation and references
Members may register inquiries or complaints with Customer Service and will be notified of appeal rights

Coverage Exclusions

Coverage Exclusions / Not Covered

The following are not covered under the outpatient formulary:

ANY of the following

Drugs not listed in the Formulary are not covered
Drug products used for cosmetic purposes are not covered
Experimental drug products or drugs used in an experimental manner are not covered
Drug products failing industry-standard patient safety screens will not be dispensed without further prescriber information

Drugs that are not listed on the Neighborhood Formulary are not covered for the outpatient benefit unless an exception is approved; this poses a denial risk for non‑formulary requests unless the prescriber pursues the established exception or prior authorization processes.

Requirements & Next Steps for Providers

Prior Authorization

Obtain Prior Authorization for PA-listed drugs

Fax a completed Prior Authorization Request to Neighborhood Pharmacy Department at 1-866-423-0945 or contact Neighborhood Pharmacy Department at 1-401-459-6020; provide clinical information demonstrating criteria for exception (e.g., contraindication, prior failure).

Include clinical rationale showing formulary products are contraindicated, previously failed, or otherwise inappropriate.
Provide relevant patient clinical history and supporting documentation with the PA request.
Use the listed fax or phone numbers to submit the request: Fax 1-866-423-0945 or Phone 1-401-459-6020.

Step Therapy

Request Step Therapy Exception when alternatives inappropriate

If required formulary products are not appropriate for the member or the member cannot take the alternatives, provider may request an exception to Step Therapy with supporting clinical rationale.

Explain why required formulary alternatives are inappropriate or cannot be taken (e.g., contraindication, intolerance, prior failure).
Provide clinical documentation of trials, adverse reactions, or other medical reasons supporting the exception request.
Requests reviewed on individual patient need against PBM/P&T–approved criteria.

Documentation Required

Respond to patient safety-screen failures

Provide additional prescriber information if a drug product fails industry-standard patient safety screens before the pharmacy will dispense.

When safety-screen checks flag a concern, supply the pharmacy with clarifying clinical details (diagnoses, current meds, monitoring plan) to resolve the screen.
Respond promptly to pharmacy requests so dispensing can proceed if clinically appropriate.

Denial Risk

Non-formulary drugs are not covered absent approved exception

Drugs not listed on the Formulary are not covered for the outpatient benefit unless an exception is granted via the PA/exception process. Emphasize that non-formulary medications will be denied absent an approved exception and that appeal rights and the adverse determination/appeals process are available per the Adverse Determination section.

If a non-formulary request is denied, the Medical Director or Physician Reviewer will explain the reason for denial and the appeals process.
Written notification will document reasons, applicable guidelines, and instructions for filing an appeal.

Formulary Governance & Definitions

The Neighborhood Formulary is developed and maintained by the PBM's Pharmacy & Therapeutics (P&T) Committee, which meets at least quarterly to consider additions and review the adequacy of the Formulary. The Committee evaluates safety, efficacy, effectiveness in real‑world use, duplication among agents, cost and outcome modeling (cost‑effectiveness and potential savings), and contractual or Exchange benefit restrictions when determining inclusion and any applicable restrictions for medications.

Therapeutic interchange: replacing a prescribed medication with a chemically different medication, with the prescribing physician's approval, expected to produce similar clinical effectiveness and outcomes; implemented on an individual basis with Neighborhood Pharmacy staff contacting the prescriber when appropriate.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNeighborhood Health Plan of Rhode Island Formulary (Exchange)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

On This Page

OpenPayer

Neighborhood Health Plan of Rhode Island Formulary (Exchange)

Coverage Summary & Scope

Formulary Coverage Criteria

Coverage Exclusions

Formulary Identification Tags

Requirements & Next Steps for Providers

Formulary Governance & Definitions

Revision History

PA	Prior Authorization required
QL	Quantity Limit
ST	Step Therapy required
OTC	Over The Counter product (some OTC covered with written prescription)