CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Age Restriction

Defines criteria for authorization of drugs/products when age restrictions are relevant for Neighborhood Health Plan of Rhode Island Medicaid members, including initial approval, continuation, documentation and coverage duration limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAge Restriction

Policy CodePolicy N/A

Change TypeClarified (non-material)

Effective DateJul 1, 2018

Next Review Date

Key ActionSubmit supporting documentation including lab values, treatment plan, and chart notes and provide rationale for age-specific use and why formulary alternatives are inappropriate when applicable.

SourceLink

POLICY UPDATE CHANGES

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

Up to 12 monthsCoverage Duration

MedicaidScope

ListedAccepted Reference Compendia

Coverage Summary

This policy defines authorization criteria for drugs/products when age restrictions apply to Neighborhood Health Plan of Rhode Island Medicaid members. Coverage stance: covered_with_criteria. Key scope statistics: Coverage Duration: Up to 12 months; Scope: Medicaid; Accepted Reference Compendia: American Hospital Formulary Service Drug information (AHFS-DI), Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs, and peer-reviewed published medical literature.

Medical-Necessity Criteria

Criteria for Approval (Initial Authorization)

An authorization may be granted when all the following criteria are met:

ALL of the following

FDA or compendia-supported indication: The requested drug/product is being used for an FDA-approved indication or a medically accepted indication as defined in any one of the following standard reference compendia: American Hospital Formulary Service Drug information (AHFS-DI), Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs, or peer-reviewed published medical literature indicating that sufficient evidence exists to support use.
Dose and quantity: The prescribed dose and quantity fall within the FDA-approved labeling or within compendia-supported dosing guidelines.
Documentation: All relevant documentation (e.g., lab values, treatment plan, medical chart notes) is provided.
Age-specific rationale: Rationale provided for why the use of the requested drug is necessary for a patient of this age.
Formulary alternatives rationale: Rationale provided for why formulary alternatives (e.g. alternative dosage forms) are not appropriate, when applicable.

Continuation of Therapy

Continuation may be approved when all of the following are met:

ALL of the following

Meets initial criteria: Patient meets all initial criteria.
Tolerance and toxicity: Patient is tolerating treatment and is not experiencing any unacceptable toxicity from the drug.
Clinical benefit: Patient has disease stabilization or improvement in disease (as defined by established clinical practice guidelines).

Coverage Duration

Coverage duration: Up to 12 months as determined by FDA guidance and internal policies and procedures.12 months

Provider Actions & Requirements

Prior Authorization

Authorization requires documentation and justification

Submit supporting documentation including relevant laboratory values, the treatment plan, and medical chart notes. Provide a clear rationale for use in the patient’s specific age group and explain why formulary alternatives (for example, alternative dosage forms) are not appropriate when applicable. This documentation supports meeting the authorization criteria.

Relevant laboratory values
Treatment plan
Medical chart notes
Rationale for age-specific use
Rationale for why formulary alternatives are inappropriate (when applicable)

Documentation Required

Dose and quantity must align with labeling or compendia

Ensure the prescribed dose and quantity fall within FDA-approved labeling or compendia-supported dosing guidelines; documentation of dosing and quantity must reflect this.

Billing Rule

Coverage duration limit

Authorizations are limited to up to 12 months in accordance with FDA guidance and internal policies and procedures.

Up to 12 months (see Coverage Duration criteria)

Definitions & Background

Authorization requires age-specific criteria: the drug must be for an FDA-approved or compendia-supported indication, dosing and quantity must align with FDA labeling or compendia guidance, and documentation must include rationale for use in the patient’s age group. For continuation, the patient must meet initial criteria, be tolerating therapy without unacceptable toxicity, and demonstrate disease stabilization or improvement.

Definitions

termMedically accepted indication

definitionAn indication supported by any one of the listed standard reference compendia or peer-reviewed published medical literature indicating sufficient evidence to support use.

Revision History

2018-07Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2019-11Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2020-04Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2021-01Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2022-01Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2023-01Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2024-01Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2025-01Review

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

2026-01ReviewLatest

Reviewed and revised multiple times with the most recent review dated 01/2026; no material clinical policy changes indicated in the revision history.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAge Restriction

Policy CodePolicy N/A

Change TypeClarified (non-material)

Effective DateJul 1, 2018

Next Review Date

SourceLink

On This Page

OpenPayer

Age Restriction

Coverage Summary

Medical-Necessity Criteria

Provider Actions & Requirements

Definitions & Background

Coding

Revision History