CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Rx_Prescription Drug Coverage In Assisted Living And Long Term Care

Notification to provider partners and dispensing pharmacies that Neighborhood Health Plan expects use of plan formularies for members in assisted living and long-term care facilities and requires prior authorization for non-formulary or restricted medications, including OTCs.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRx_Prescription Drug Coverage In Assisted Living And Long Term Care

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

Key ActionProviders are expected to utilize Neighborhood drug formularies when creating drug treatment plans for members in assisted living and long-term care facilities; submit a Prior Authorization for non-formulary or restricted medications before dispensing.

SourceLink

POLICY UPDATE CHANGES

Affirms expectation that providers use Neighborhood formularies and requires prior authorization for non-formulary or restricted medications for assisted living and long-term care members.

1Key Action Items

Policy Overview

Background: Neighborhood News bulletin reminding providers that Neighborhood expects use of plan drug formularies to ensure safe and cost-effective treatment for members residing in assisted living and long-term care facilities.

Scope summary: Notification to provider partners and dispensing pharmacies that providers must utilize Neighborhood formularies when creating drug treatment plans for assisted living and long-term care members and that Prior Authorization is required for non-formulary or restricted medications, including over-the-counter (OTC) drugs. The most up-to-date formularies are posted by line of business on the payer website at www.nhpri.org/providers/provider-resources/pharmacy/. Dispensing pharmacies may request that providers submit a Prior Authorization prior to placing an override and dispensing.

Required Provider Actions

Documentation Required

Use of Neighborhood Formularies

Providers are expected to utilize Neighborhood drug formularies when creating drug treatment plans for members in assisted living and long-term care facilities; the most up-to-date formularies are posted on the payer website.

Prior Authorization

Prior Authorization Required for Non-Formulary or Restricted Drugs

If a member requires a drug not on their formulary or a medication that has a restriction (including non-formulary OTC drugs), providers must submit a Prior Authorization to obtain approval before dispensing.

Prior Authorization

Pharmacy Request for Prior Authorization

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