CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medications Covered Under the Pharmacy Benefit Only

Defines pharmaceutical products that are covered exclusively under the pharmacy benefit (not the medical benefit) for Neighborhood Health Plan of Rhode Island commercial members, including prior authorization requirement and member notification when benefit changes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedications Covered Under the Pharmacy Benefit Only

Policy CodePolicy N/A

Change TypeAdministrative review

Effective Date

Next Review Date

Key ActionHemlibra (emicizumab) will be covered only through the pharmacy benefit and requires prior authorization when clinical criteria are met under the pharmacy benefit.

POLICY UPDATE CHANGES

Policy last reviewed 4/2021, 6/2022, 5/2023; lists Hemlibra as covered exclusively on the pharmacy benefit.

1Medications listed as pharmacy-only

Coverage Summary

This policy defines that certain medications are covered exclusively through the pharmacy benefit rather than the medical benefit. Members and providers will receive a 60-day advance notification if the member obtained the medication under the medical benefit within the previous 180 days.

Pharmacy Benefit Exclusive Coverage

The following pharmaceutical products are covered and available exclusively on the Pharmacy Benefit:

Product covered exclusively under pharmacy benefit: Product listed is covered exclusively under the pharmacy benefit
Prior authorization required under pharmacy benefit: Coverage is subject to prior authorization when clinical criteria are met under the pharmacy benefit
60-day advance notification for recent medical benefit recipients: Members who obtained the medication under the medical benefit within the previous 180 days will receive a 60-day advance notification of the change in benefit coverage

ref": "b0_1

title": "Pharmacy Benefit Exclusive Coverage

Provider Actions

Prior Authorization

Prior authorization required under pharmacy benefit

Hemlibra (emicizumab) will be covered only through the pharmacy benefit and requires prior authorization when clinical criteria are met under the pharmacy benefit.

Hemlibra

Documentation Required

Member notification for benefit change

If a member obtained the medication under the medical benefit within the previous 180 days, the member and providers must be given a 60-day advance notification of the change to pharmacy benefit coverage.

Hemlibra
60-day advance notification
180-day lookback

Background

Neighborhood Health Plan of Rhode Island (Scope: Commercial) identifies medications that will be covered only through the pharmacy benefit rather than the medical benefit. The policy lists Hemlibra (emicizumab) as covered exclusively on the pharmacy benefit and subject to pharmacy prior authorization when clinical criteria are met.

Members and providers will receive a 60-day advance notification if the member obtained the medication under the medical benefit within the previous 180 days. Policy administrative review dates include 4/2021, 6/2022, and 5/2023.

Revision History

2021-04-01administrative review

Policy last reviewed 4/2021; lists Hemlibra as covered exclusively on the pharmacy benefit. No clinical policy statement changes indicated in source; administrative review only (non-material).

2022-06-01administrative review

Policy last reviewed 6/2022; lists Hemlibra as covered exclusively on the pharmacy benefit. No clinical policy statement changes indicated in source; administrative review only (non-material).

2023-05-01administrative reviewLatest

Policy last reviewed 5/2023; lists Hemlibra as covered exclusively on the pharmacy benefit. No clinical policy statement changes indicated in source; administrative review only (non-material).