CurrentNeighborhood Health Plan of Rhode IslandPolicy 000826

Benefit Exclusion

Lists medications and medication classes that are excluded from coverage under Neighborhood Health Plan of Rhode Island pharmacy and medical benefits for Medicaid, Commercial, and INTEGRITY (Medicare-Medicaid) members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBenefit Exclusion

Policy CodePolicy 000826

Change TypeNo material change

Effective DateJul 26, 2019

Next Review DateJan 26, 2023

Key ActionDo not bill for drugs listed as exclusions; claims for excluded products will be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20distinct exclusion items

Medicaid, Commercial, INTEGRITYpopulations

Medicaid onlyACIP exception

MDRPMDRP required

Benefit Exclusions and Scope

Benefit Exclusions (by benefit type)

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Pharmacy Benefit — Medicaid exclusions (when obtained at a pharmacy): Excluded items include: biological products for allergy immunizations and vaccinations; blood fractions; compound medications that are not made up of at least one legend drug; drugs prescribed or dispensed outside of Health Plan dispensing guidelines; drugs not proven effective according to the FDA; drugs used for cosmetic purposes; drugs or products whose manufacturer does not participate in the Medicaid Drug Rebate Program (MDRP); experimental drugs (including DESI notice items); medications provided while resident in an institution that provides drugs as part of services; non-medical substances; off-label use of drugs unless mandated by laws pertaining to treatment of cancer; support garments and other durable medical equipment (except diabetic testing supplies); therapeutic devices and appliances (except when used to administer insulin or for self-administration of FDA‑approved injectable drugs); medications for sexual or erectile dysfunction; medical marijuana; travel medications and vaccines for diseases associated with foreign travel (e.g., malaria, typhoid) — note: travel vaccines recommended by ACIP are covered for Medicaid members; medications for infertility treatment.

ACIP-recommended travel vaccines are an exception and are covered for Medicaid members.

Medical (buy-and-bill) Benefit exclusions: Excluded when billed by a provider (buy-and-bill/medical benefit): drugs for cosmetic purposes; drugs whose manufacturer does not participate in the MDRP; experimental drugs or drugs used experimentally (unless mandated by laws pertaining to cancer); medications for infertility, sexual or erectile dysfunction; medical marijuana; travel medications and vaccines related to foreign travel (ACIP travel vaccine exception for Medicaid); off-label use of drugs not covered unless cancer laws mandate.

Commercial Benefit exclusions: Excluded: any drug product used for cosmetic purposes; experimental products or off-label/experimental use (unless mandated by laws pertaining to cancer); medications for sexual and erectile dysfunction; medical marijuana.

INTEGRITY (Medicare-Medicaid Plan) exclusions: Excluded: medications for sexual or erectile dysfunction; medications for infertility; medications used for indications that are not FDA‑approved or compendia‑supported; medications used inconsistently with applicable NCD/LCD requirements where such determinations exist; continuous glucose monitors that do not meet CMS' definition of a therapeutic CGM (e.g., Freestyle Libre 3). Per 42 CFR 422.101, this policy applies to INTEGRITY only in the absence of an NCD or LCD.

Additional exclusions (general): Compounded products lacking at least one legend drug; prescription and OTC homeopathic drugs; non‑drug therapeutic/prosthetic devices, appliances, supports (except diabetic testing supplies); drugs without FDA approval or whose approval has been withdrawn; prescriptions filled at non‑Neighborhood network retail pharmacies except for emergency care; prescription drugs when the same active ingredient is available OTC or when packaged with non‑prescription products; OTC drugs/products not on the NHPRI formulary are not covered.

All items listed in the policy's exclusion tables are explicit benefit exclusions and therefore not covered when billed under the applicable Neighborhood benefit. These exclusions apply across the Pharmacy, Medical (buy-and-bill), Commercial, and INTEGRITY (Medicare‑Medicaid) benefit pathways as specified in the criteria sets.

An important exception: travel vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) are covered for Medicaid members. Apart from that exception, products that fall into the listed exclusion categories (for example, cosmetic treatments, medical marijuana, experimental products, drugs from manufacturers not participating in the Medicaid Drug Rebate Program, infertility and sexual/ED medications, and travel prophylaxis not ACIP‑recommended) are not covered.

Provider Actions, Billing, and Denials

Prior Authorization

Prior authorization

This policy is an exclusions list — prior authorization does not apply. Prescriptions filled at pharmacies other than Neighborhood network retail pharmacies are not covered except for emergency care.

Billing Rule

Provider billing notice

Providers should bill in accordance with the payer's dispensation rules. Prescriptions or drugs billed under a buy-and-bill/medical benefit that fall into the exclusions below will be denied. Ensure claims contain documentation showing drugs are FDA-approved and supplied by manufacturers participating in the Medicaid Drug Rebate Program when applicable. Fill prescriptions at Network retail pharmacies to avoid denial unless the situation is an emergency.

Denial Risk

Denial triggers — benefit exclusions

The following items are benefit exclusions and are denial triggers when claims are submitted (pharmacy or medical/buy-and-bill) — do not bill Neighborhood for these: biologicals for allergy immunizations or vaccinations; blood fractions; compound medications not containing at least one legend drug; products from manufacturers not participating in the Medicaid Drug Rebate Program (MDRP); experimental drugs (including DESI-noticed products); drugs not FDA-approved or whose approval has been withdrawn; off‑label uses (except legally mandated cancer treatments); cosmetic-use drugs; non‑medical substances and non‑drug prosthetic/therapeutic devices and supports (except diabetic testing supplies); therapeutic devices and appliances including needles/syringes except for insulin or FDA‑approved injectable self-administration; medications for sexual/erectile dysfunction or infertility; medical marijuana; travel medications and most travel vaccines (note: ACIP-recommended travel vaccines are covered for Medicaid members); prescriptions filled at non‑network pharmacies (except emergency); prescription drugs once the same active ingredient is available OTC; prescriptions packaged with non-prescription products; OTC products unless listed on the formulary; homeopathic OTC/prescription products; certain continuous glucose monitors that do not meet CMS therapeutic CGM definition for INTEGRITY members; and medications used inconsistently with NCD/LCD requirements.

Biologicals for allergy immunizations and vaccinations
Blood fractions
Compounded products without ≥1 legend drug
Manufacturers not in the MDRP
Experimental drugs (including DESI)
Drugs not FDA-approved or with withdrawn approval
Off‑label uses (except mandated cancer treatments)
Cosmetic-use drugs
Non‑medical substances
Therapeutic devices/appliances and non‑drug prosthetics (except diabetic testing supplies)

Key Definitions

Therapeutic Continuous Glucose Monitor (therapeutic CGM)

DefinitionTherapeutic Continuous Glucose Monitor (therapeutic CGM) — device subject to CMS' definition of a therapeutic CGM; only devices meeting that CMS definition are considered covered under the INTEGRITY benefit.

INTEGRITY exclusion exampleDevices that do NOT meet CMS' therapeutic CGM definition are excluded from INTEGRITY coverage (example: Freestyle Libre 3).

Regulatory noteThis policy applies to INTEGRITY (MMP) only in the absence of a National Coverage Determination (NCD) or Local Coverage Determination (LCD) per 42 CFR 422.101.

Related excluded itemsContinuous glucose monitors that fail to meet CMS criteria are treated similarly to other INTEGRITY exclusions such as medications for sexual dysfunction and infertility.

Background and Policy Purpose

This policy catalogs Neighborhood Health Plan of Rhode Island's medication and product exclusions across both pharmacy and medical billing pathways. It distinguishes exclusions that apply when a product is obtained at a retail pharmacy versus when a drug is billed under the medical (buy‑and‑bill) benefit, and it also lists exclusions specific to Commercial and INTEGRITY (MMP) benefits.

The background clarifies key programmatic rules that inform these exclusions, including the requirement that manufacturers participate in the Medicaid Drug Rebate Program for Medicaid coverage, that continuous glucose monitoring devices must meet CMS' therapeutic CGM definition to be covered under INTEGRITY, and that prescriptions filled at non‑NHPRI network retail pharmacies are not covered except in emergency care situations.

OpenPayer

Benefit Exclusion

Benefit Exclusions and Scope

Provider Actions, Billing, and Denials

Where Drugs May Be Filled

Key Definitions

Background and Policy Purpose