CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Formulary Exception / Prior Authorization Request Form

A fax form used by participating providers to request a formulary exception or prior authorization for medications, capture patient/prescriber/clinical information, and document criteria such as FDA/compendia support, dosing, rationale, trials of formulary alternatives, intolerance/contraindications, and continuation of therapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFormulary Exception / Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed Formulary Exception Prior Authorization Form with required documentation to Neighborhood at 1-866-423-0945 or use CoverMyMeds for real-time coverage determinations.

POLICY UPDATE CHANGES

No material clinical or coverage changes

FormDocument Type

Fax or CoverMyMedsSubmission Methods

24-hrExpedited Decision Available

Policy summary

This Formulary Exception / Prior Authorization Request Form collects the clinical and administrative information needed for participating providers to request a formulary exception or prior authorization from Neighborhood Health Plan of Rhode Island. It is used to document patient and prescriber details, diagnosis and medication information, and the clinical justification for a non-formulary or prior authorization request. The prescriber must complete all required criteria questions on the form, sign and date to certify accuracy, and include required identifiers such as NPI and contact information.

Formulary exception documentation criteria

Formulary Exception Criteria Questions (for documentation on the form)

The prescriber is asked to document answers to ALL of the following criteria questions to support a formulary exception request:

ALL of the following

Is the requested drug/product used for an FDA indication supported in the compendia of current literature (examples: AHFS, Micromedex, current accepted guidelines)?
Documentation of diagnosis required
Does the prescribed dose and quantity fall within FDA-approved labeling or within compendia-supported guidelines?
Prescriber must document the dose the member will be taking
Is there rationale for why the requested product is medically necessary?
Prescriber must explain medical necessity
Continuation of therapy
- Is this request for continuation of therapy?
  If yes, provide start date of therapy
- If continuation: Is patient tolerating treatment and not experiencing unacceptable toxicity from the drug?
- If continuation: Does the patient have disease stabilization or improvement as defined by established clinical practice guidelines?
  Provide explanation
Formulary alternatives tried
- Has the member tried and failed the required number of formulary alternatives for the given diagnosis?Requirement: 2 in class with 2 or more alternatives, or 1 in a class with only 1 alternative; documentation of trials required for approval
- Is the patient unable to take the required number of formulary alternatives due to intolerance, expected adverse reaction, patient-specific reasons, or contraindication?
  If yes, documentation of intolerance/contraindication required
If the requested is a combination product, the separate individual components taken concurrently must be unable to be taken plus the remaining number of alternatives
Documentation required
If the requested is a brand product and has a formulary generic with the same active ingredient, the formulary generic must be unable to be taken plus the remaining number of alternatives
Documentation required
If the requested has an available alternative formulary dosage form of the same active ingredient, the alternative formulary dosage form must be unable to be taken plus the remaining required number of formulary alternativesRequirement applies only if clinically appropriate (same indication, age appropriateness, drug interactions)
Documentation required

Form completion and submission instructions

What the prescriber must do

Prior Authorization

Submit completed formulary exception prior authorization

Fax the completed Formulary Exception Prior Authorization Form with required documentation to Neighborhood at 1-866-423-0945, or use CoverMyMeds for real-time coverage determinations.

Documentation Required

Document clinical support and trials

Provide documentation of diagnosis, compendia support, dosing, rationale for medical necessity, start date for prior therapy, trial history and reasons for failure or intolerance of formulary alternatives, and any other clinically relevant information requested on the form.

Prior Authorization

Expedited decision request option

If waiting for a standard decision could seriously harm the member's life, health, or ability to function, check the expedited decision box to request an expedited (fast) decision; expedited decisions are requested to be completed within 24 hours.

Documentation Required

Prescriber attestation

The prescriber must sign and date certifying accuracy and completeness and include prescriber name, NPI, office phone, fax, and address on the form.

Who and when this form applies

This fax form is used by participating providers to request a formulary exception or prior authorization for medications by capturing patient, prescriber, and clinical information and by documenting required criteria such as whether the request is for an FDA indication supported by compendia (examples: AHFS, Micromedex, current accepted guidelines), whether dosing falls within FDA labeling or compendia-supported guidelines, rationale for medical necessity, trial history of required formulary alternatives (or reasons the member is unable to take them), and continuation‑of‑therapy details including tolerance and clinical response.

Submission MethodsFax or CoverMyMeds

Affected usersParticipating providers / Prescribers

PurposeRequest formulary exception or prior authorization for medications

Form references and supporting guidance

The form specifically references compendia support and formulary alternative trial requirements to substantiate non‑formulary requests (examples cited on the form include AHFS and Micromedex and current accepted guidelines). It requires documentation that the member has tried and failed the required number of formulary alternatives (requirement examples: 2 in a class with 2 or more alternatives, or 1 in a class with only 1 alternative), or documentation of intolerance/contraindication when alternatives cannot be used.