CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

2023 Commercial Formulary Foreword

Describes the Neighborhood Health Plan of Rhode Island Commercial outpatient drug formulary purpose, development, governance by the P&T committee, general coverage limitations, prior authorization, step therapy, exception/appeal processes, therapeutic interchange, and pharmacist/prescriber communications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policy2023 Commercial Formulary Foreword

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionWhen a prescription for a PA-listed drug is presented, fax a completed PA request to 1-866-423-0945 or call 1-855-321-9244 and provide requested information; requests are reviewed per PBM P&T criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were identified in this update.

QuarterlyP&T Committee Meeting Frequency

Outpatient onlyFormulary Applies To

VariedDrug restrictions (PA/QL/ST/C/OTC)

Formulary Foreword — Scope & Governance

Background: The formulary is maintained by Neighborhood Health Plan of Rhode Island and is the list of medications covered under the pharmacy component of the Commercial benefit. It outlines rationale and processes used to define the Formulary for prescribers, pharmacists, and members.

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General Coverage Provisions & Processes

General Formulary Coverage Provisions

The Formulary applies to outpatient drugs; coverage is subject to the following general provisions:

OTC prescription requirement: Some Over-the-Counter (OTC) products are covered for members; a written prescription is required for OTC products.
Non-formulary not covered: Drug Products not listed in the Formulary at www.nhpri.org are not covered.
Cosmetic exclusions: Any drug products used for cosmetic purposes are not covered.
Experimental exclusions: Experimental drug products, or any drug products used in an experimental manner are not covered.
Lost/stolen replacement: Replacement of lost or stolen medications will be covered on a case-by-case basis.
Patient safety screens: Drug products failing industry-standard patient safety screens will not be dispensed at the pharmacy without further information from the prescriber.

Exception / Non-Formulary Request Criteria

When requesting coverage for a non-formulary medication, prescribers should provide information addressing at least one of the following:

Contraindication to formulary: The use of Formulary products is contraindicated in the patient.
Prior trial failure: The patient has failed an appropriate trial of Formulary or related agents.
Formulary not suited for care need: The choices available in the Drug Formulary are not suited for the present patient care need, and the drug selected is required for patient safety.
Formulary may provoke condition: The use of a Formulary Drug may provoke an underlying condition, which would be detrimental to patient care.

Adverse Determination / Denial Process

If a non-formulary request does not meet exception criteria, Neighborhood follows these steps:

Provide rationale and alternatives: Provide the rationale and Formulary alternatives to the prescribing provider.
Refer to Medical Director/Reviewer: Refer prescriber to the Neighborhood Medical Director or Physician Reviewer for assessment of medical necessity if prescriber disagrees with recommended alternatives.
Denial discussion and written notice: If denied, Medical Director or Physician Reviewer will discuss reasons for denial, explain appeals process, and provide written notice to prescriber and member documenting reasons, applicable benefit or clinical guideline, and appeal instructions.
Member inquiries and complaints: Members may register an inquiry or complaint with Member Services to be responded to with standard protocols and notification of appeal rights.

PA: Prior Authorization — approval required before coverage at point of dispensing; prescriber or representative may fax a completed PA request to 1-866-423-0945 or call 1-855-321-9244 to initiate review.

QL: Quantity Limit — a limit on the quantity of medication allowed per fill or time period as noted in the Formulary.

ST: Step Therapy — required trial of specified formulary products prior to coverage of the requested medication; providers may request an exception if required formulary products are not appropriate for the member.

C: Charge/Dispense up to 365 days — drugs listed as 'C' may be dispensed at retail pharmacy for up to 365 days' supply in one fill.

OTC: Over-the-Counter — some OTC products are covered for members but a written prescription is required for OTC products to be covered.

Prior Authorization, Step Therapy, Therapeutic Interchange

Prior Authorization (PA)

Drugs listed as PA require approval at point of dispensing; to obtain coverage:

How to submit Prior Authorization

Fax PA request: Fax a completed Prior Authorization Request to the Neighborhood Pharmacy Department at 1-866-423-0945.
Call Neighborhood: Contact Neighborhood at 1-855-321-9244 and provide all necessary information requested.

Review criteria for PA

Individualized and P&T criteria: Each request will be reviewed on individual patient need and according to criteria approved by the PBM's P&T Committee.

Step Therapy (ST)

Drugs listed as ST require trials of specified formulary products prior to coverage of the requested medication:

Required trial of formulary products: Member must try additional formulary products (per step therapy requirements) prior to initiating the requested medication.
Exception to Step Therapy: Provider can request an exception to Step Therapy if required formulary products are not appropriate for the member or there is a reason the member cannot take the formulary alternatives.

Therapeutic Interchange

Therapeutic interchange may occur with prescriber's approval when appropriate:

Pharmacy-initiated interchange with prescriber approval: Pharmacy staff may replace a prescribed medication with a chemically different medication expected to produce similar clinical effectiveness, with prescriber's approval; Neighborhood Pharmacy staff will contact prescriber's office if interchange is appropriate.

What Prescribers & Pharmacies Must Do

Prior Authorization

Obtain PA for drugs listed as PA

When a prescription for a PA-listed drug is presented, the prescriber or representative must fax a completed PA request to 1-866-423-0945 or call 1-855-321-9244 and provide requested information; requests are reviewed per PBM P&T criteria.

Step Therapy

Comply with step therapy requirements or request exception

For ST-listed drugs, ensure required formulary products have been tried and failed or submit documentation supporting a step therapy exception.

Documentation Required

Provide clinical rationale for non-formulary exceptions

When requesting non-formulary coverage, prescriber must document at least one of: formulary products are contraindicated, the patient has failed appropriate trials of formulary or related agents, the formulary choices are not suited and the selected drug is required for patient safety, or use of a formulary drug may provoke an underlying condition.

Documentation Required

Respond to patient safety screen failures

Drug products failing industry-standard patient safety screens will not be dispensed at the pharmacy without further information; the pharmacy will require additional information from the prescriber before dispensing.

Billing Rule

OTC prescription requirement

Some covered Over-the-Counter (OTC) products require a written prescription; a written prescription is required for OTC products that are covered, which affects dispensing and billing.

OpenPayer

2023 Commercial Formulary Foreword

Formulary Foreword — Scope & Governance

General Coverage Provisions & Processes

Prior Authorization, Step Therapy, Therapeutic Interchange

Priority Contacts and Submission Channels

What Prescribers & Pharmacies Must Do

Document Dates & Review

1-866-423-0945	Prior Authorization fax number for Neighborhood Pharmacy Department
1-855-321-9244	Neighborhood general contact / Member Services phone number