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, coverage limitations, prior authorization, step therapy, exception process, therapeutic interchange, generic substitution, and adverse determination processes. Does not govern inpatient medications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNeighborhood Health Plan of Rhode Island Commercial Drug Formulary

Policy CodePolicy N/A

Change TypeN/A

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionFor drugs listed as PA, prescribers or their representatives must fax a completed PA request to 1-866-423-0945 or call 1-855-321-9244 and provide necessary information; each request is reviewed per PBM P&T Committee criteria.

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief.

OutpatientScope

QuarterlyP&T Frequency

PA/QL/ST/CControl Mechanisms

Policy Overview & Scope

This document defines the outpatient pharmacy formulary for Neighborhood Health Plan of Rhode Island Commercial members and explains formulary development, coverage limitations, prior authorization, step therapy, exception process, therapeutic interchange, generic substitution, and adverse determination processes. It does not govern inpatient medications. The formulary is maintained for use by prescribers, pharmacists, and members.

Coverage Conditions & Formulary Rules

General Formulary Coverage Conditions

Formulary applies to outpatient drugs and establishes conditions under which drugs are covered or excluded:

Listed on Formulary: Drug must be listed on the Neighborhood Formulary (online or PDF) to be covered for outpatient benefit.
OTC prescription: A written prescription is required for covered Over-the-Counter (OTC) products.
Cosmetic exclusions: Drugs used for cosmetic purposes are not covered.
Experimental exclusions: Experimental drugs or drugs used in an experimental manner are not covered.
Lost/stolen replacement: Replacement of lost or stolen medications covered on a case-by-case basis.
Safety screens: Drugs failing industry-standard patient safety screens will not be dispensed without further prescriber information.

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Generic Substitution

Generic use expectation:

Generic Substitution: When available, FDA-approved generic drugs are to be used in all situations; generics are subject to PBM P&T Committee review.

Therapeutic Interchange

Therapeutic interchange may occur with prescriber approval when clinically appropriate:

Therapeutic Interchange: Neighborhood Pharmacy staff will contact prescriber's office if therapeutic interchange is appropriate; interchanged agents expected to produce similar clinical effectiveness with prescriber's approval.

Prior Authorization, Step Therapy, Exceptions & Appeals

Prior Authorization (PA) Requirements

Drugs listed with 'PA' require prior authorization. To obtain coverage:

Contact methods for PA: Prescriber or prescriber's representative may fax a completed Prior Authorization Request to the Neighborhood Pharmacy Department at 1-866-423-0945; or prescriber may call Neighborhood at 1-855-321-9244 and provide necessary information.

PA review criteria: Each PA request is reviewed on individual patient need and according to criteria approved by the PBM's P&T Committee.

Step Therapy (ST) Requirements

Drugs listed with 'ST' require step therapy:

Step Therapy requirements: Member must try required formulary products prior to initiating the requested medication; provider may request an exception to Step Therapy if required formulary products are inappropriate or not tolerated for the member.

Exception Process for Non-Formulary Coverage

Non-formulary coverage may be requested when criteria apply:

Exception clinical reasons: Formulary products are contraindicated; or patient has failed an appropriate trial of formulary or related agents; or use of a Formulary drug may provoke an underlying condition detrimental to patient care; or choices in the Drug Formulary are not suited and the selected drug is required for patient safety.

Exception request process: When a member presents a prescription for a non-formulary drug, the dispensing pharmacist evaluates drug history and contacts prescriber; prescriber must call or fax Neighborhood to request coverage and provide information addressing the exception criteria.

Adverse Determination / Denial Process

Process when requests do not meet benefit exception criteria:

Prescriber referral and review: Prescriber may be referred to Neighborhood Medical Director or Physician Reviewer for discussion; Medical Director assesses medical necessity before determination.

Rationale and alternatives: Rationale and formulary alternatives will be provided to the prescribing provider.

Denial notices: In the event of denial, written letters will be provided to prescriber and member documenting reasons, applicable benefit or clinical guideline, opportunity to review documentation, and the appeal process.

Member services and appeals: Members may register an inquiry or complaint with Member Services; response follows standard protocols and notification of appeal rights.

Prior Authorization

Prior Authorization submission

For drugs listed as PA, prescribers or their representatives must fax a completed PA request to 1-866-423-0945 or call 1-855-321-9244 and provide necessary information. Each request is reviewed per the PBM's P&T Committee criteria.

Fax Prior Authorization Request to 1-866-423-0945
Call Neighborhood at 1-855-321-9244 to provide necessary information

Step Therapy

Step Therapy exception requests

If formulary-required products are inappropriate, the provider must request an exception to Step Therapy explaining why the required formulary alternatives cannot be used for the member.

Documentation Required

Exception supporting documentation

When requesting non-formulary coverage, the prescriber must provide documentation addressing contraindication to formulary products, prior failure of appropriate formulary or related agents, safety concerns that would make formulary use detrimental, or that the selected drug is required for patient safety.

Denial Risk

Adverse Determination appeal rights

If a request is denied, the prescriber may be referred to the Neighborhood Medical Director or Physician Reviewer for discussion and assessment of medical necessity. The Medical Director/Reviewer will provide written notice to prescriber and member documenting reasons for the decision, applicable benefit or clinical guideline, and instructions for filing an appeal; members may also contact Member Services to register an inquiry or complaint.

Billing Rule

OTC prescription requirement

A written prescription is required for covered Over-the-Counter (OTC) products.

Formulary Indicators & Code Groups

Formulary requirement indicators (informational, not procedure codes)mixed

PA	Prior Authorization required
QL	Quantity Limit
ST	Step Therapy required
OTC	Over-the-Counter product
C	Can be dispensed for up to 365 days' supply in one fill

The document uses informational formulary requirement indicators to describe coverage controls; these are not billing or procedure codes and are intended to communicate coverage expectations in the formulary.

Key indicators include: PA (Prior Authorization required), QL (Quantity Limit), ST (Step Therapy required), OTC (Over-the-Counter product), and C (can be dispensed for up to 365 days' supply in one fill).

Intended use: to signal control mechanisms applied to listed drugs (e.g., PA, QL, ST, C) and guide prescribers, pharmacists, and members on when prior authorization, step therapy, or quantity limits apply and how to request coverage or exceptions.

Definitions

Term	Definition
Therapeutic Interchange	Replacing a prescribed medication with a chemically different medication expected to produce similar clinical effectiveness, done with prescriber's approval.
Step Therapy (ST)	Requirement that a member try specified formulary products prior to initiating the requested medication.
Prior Authorization (PA)	A requirement for approval from the plan before a drug will be covered.

Neighborhood's Formulary is maintained by the Pharmacy & Therapeutics (P&T) Committee, which meets at least quarterly to consider additions and review the formulary. The P&T Committee evaluates drugs using criteria including efficacy, safety, effectiveness, potential duplication, cost-effectiveness, and contract requirements, and the formulary is provided as a tool for prescribers, pharmacists, and members to understand covered outpatient medications and the process for exceptions and appeals.

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