CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacy_Prescription Drug Coverage In Assisted Living And Long Term Care Facilities_July 2022

Defines expectations for use of Neighborhood Health Plan formularies and prior authorization processes for members residing in assisted living and long-term care facilities; applies to providers and dispensing pharmacies serving these members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy_Prescription Drug Coverage In Assisted Living And Long Term Care Facilities_July 2022

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProviders must submit a Prior Authorization to Neighborhood when a member requires a drug not on their formulary, including non-formulary OTC drugs or drugs with utilization management restrictions.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

1Primary Policy Purpose

Policy summary

Neighborhood Health Plan expects providers and dispensing pharmacies serving members in assisted living and long-term care facilities to use Neighborhood drug formularies when creating drug treatment plans. The plan requires that if a member needs a drug not on their respective formulary — including non-formulary over-the-counter (OTC) drugs or medications that have a utilization management (UM) restriction — the provider must submit a Prior Authorization to Neighborhood for approval before the medication is dispensed.

Dispensing pharmacies serving assisted living and long-term care members may request that providers submit a Prior Authorization for drugs with UM restrictions (including non-formulary and OTC drugs) prior to placing an override and dispensing the medication.

When prior authorization is required

Prior Authorization Requirement for Non-Formulary or Restricted Drugs

Covered when ALL of the following are met:

ALL of the following

Member requires a drug that is not on their respective formulary
Includes non-formulary over-the-counter (OTC) drugs or medications that have a utilization management (UM) restriction
Provider must submit a Prior Authorization request to Neighborhood

Pharmacy and provider responsibilities

Pharmacy/Dispensing Overrides for Restricted Drugs

Pharmacies may request provider action when dispensing restricted drugs:

ALL of the following

Dispensing pharmacies servicing assisted living and long-term care members may request that providers submit a Prior Authorization for drugs with UM restrictions (including non-formulary and OTC)
Providers must obtain Neighborhood approval prior to placing an override and dispensing the medication

Prior Authorization

Prior Authorization for Non-Formulary or Restricted Drugs

Providers must submit a Prior Authorization to Neighborhood when a member requires a drug not on their formulary, including non-formulary OTC drugs or drugs with utilization management restrictions.

Prior Authorization

Pharmacy-Initiated Prior Authorization Request

Dispensing pharmacies may request that the provider submit a Prior Authorization for drugs with UM restrictions before placing an override and dispensing medication to assisted living or long-term care members.

Documentation Required

Use of Neighborhood Formularies

Providers are expected to utilize Neighborhood drug formularies when creating drug treatment plans for members residing in assisted living and long-term care facilities.

Who this applies to

Key policy fields

Applies toDefines expectations for use of Neighborhood Health Plan formularies and prior authorization processes for members residing in assisted living and long-term care facilities; applies to providers and dispensing pharmacies serving these members.

SettingsAssisted living and long-term care facilities

Affected partiesProviders and dispensing pharmacies

Coverage stanceinformational