Medicaid Pharmacy Benefit Only Policy
Identifies specific medications that are covered exclusively through the Medicaid pharmacy benefit (not the medical benefit) and notes that these medications will require prior authorization under the pharmacy benefit. Members/providers receive 60-day advance notice if benefit changes for members who received the medication under the medical benefit within prior 180 days.
No material clinical or coverage changes — policy clarifies medications are covered under the pharmacy benefit with prior authorization.
Policy Summary
Subject: Medications Covered Under the Medicaid Pharmacy Benefit Only. Payer: Neighborhood Health Plan of Rhode Island. Policy title: Medicaid Pharmacy Benefit Only Policy. Policy number: N/A. Effective date: .
Background: This administrative policy identifies specific medications that are shifted to be covered only via the Medicaid pharmacy benefit rather than the medical benefit and references the NHPRI Formulary Management Policy and Procedure. The listed medications (Firazyr, Dupixent, botulinum toxin products including Botox, Dysport, Myobloc and Xeomin, Lumizyme, Nexviazyme, and Tepezza) will be covered exclusively under the pharmacy benefit and will require prior authorization when clinical criteria are met under the pharmacy benefit.
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