CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

General Prior Authorization form for medically administered medications

Defines prior authorization requirements for medically administered medications without drug-specific criteria across Medicaid, Commercial, and Medicare members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGeneral Prior Authorization form for medically administered medications

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 13, 2019

Next Review DateMay 7, 2025

Key ActionSubmit prior authorization with correct HCPCS code/units, FDA-consistent dosing, and all supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicaid, Commercial, MedicareLines of business covered

Initial + continuationAuthorization phases

365 daysMedicare lookback

6 monthsContinuation duration

Coverage Criteria for Medically Administered Medications

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Initial Therapy

Covered when ALL of the following are met

Initial Coverage Criteria: 1) Medication is used for an FDA‑approved indication or a medically accepted indication as defined in standard reference compendia (e.g., AHFS‑DI, Thomson/peer‑reviewed literature); 2) The request uses the correct HCPCS code and units; 3) Dosing is according to FDA guidelines; 4) All relevant documentation (e.g., lab values, treatment plan, medical chart notes) is provided; 5) Patient follows established clinical practice guidelines for treatment of their condition; 6) If requesting a reference product when a biosimilar is available, the patient has documented failure, intolerance, or contraindication to the biosimilar unless such biosimilars do not exist; OR the patient has experienced inadequate response or intolerance to all first‑line agents (including generics when available); 7) For Medicare members, prior receipt of the same medication within the past 365 days removes Step Therapy requirements.

Logical mix includes AND requirements with OR fallback statements for prior therapies/biosimilar reasons.

Continuation Therapy

Continuation of therapy covered when ALL of the following are met

Continuation Criteria: 1) Patient continues to meet all initial coverage criteria; 2) Patient is tolerating treatment and is not experiencing unacceptable toxicity from the drug; 3) Patient has disease stabilization or improvement as defined by established clinical practice guidelines.

Continuation authorization requires documented benefit and tolerability.

Coverage for medically administered medications without individualized drug-specific criteria is limited to uses supported by recognized authorities. Requests will be reviewed only when the medication is used for an FDA-approved indication or a medically accepted indication as defined by standard reference compendia or peer-reviewed literature (for example, AHFS-DI, Thomson Micromedex DrugDex, Clinical Pharmacology, or Wolters Kluwer Lexi-Drugs). Dosing must align with those same sources and supporting clinical documentation (e.g., treatment plan, relevant lab values, chart notes) must be provided to substantiate the requested use.

Therapies used investigationally are excluded from coverage. Specifically, drugs administered at a dose or for a condition that is not recognized as a medically accepted indication in any one of the standard compendia cited (AHFS-DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs) or supported by peer-reviewed published medical literature demonstrating sufficient evidence will be considered investigational and are not covered.

Initial Therapy Requirements

Initial

Initial coverage requirements for medically administered medications without drug-specific criteria

Initial: Medication used for an FDA‑approved or compendia‑supported (medically accepted) indication; request submitted with correct HCPCS code and units; dosing per FDA guidelines; all relevant supporting documentation provided; patient managed according to established clinical practice guidelines; biosimilar/step therapy logic applied as specified (documented failure/intolerance/contraindication to biosimilar or inadequate response/intolerance to first‑line agents).

Includes Medicare-specific note about prior receipt within 365 days affecting step therapy.

Provider Actions, Requirements, and Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for medically administered medications under the medical benefit. Requests must include the correct HCPCS codes and units and must follow the payer's prior authorization process. Failure to obtain prior authorization may result in non-payment.

Use correct HCPCS code and units on the request
Follow Neighborhood Health Plan of Rhode Island prior authorization procedures

Step Therapy

Step Therapy and Biosimilar Preference

When a biosimilar is available, the reference (brand) product will only be approved when there is documented failure, intolerance, or contraindication to the biosimilar. Step therapy requirements apply to ensure use of preferred or first‑line agents before approval of non‑preferred products.

Documented failure, intolerance, or contraindication to the biosimilar required to request reference product
Step therapy applies to first‑line agents and generics when available

Documentation Required

Required Documentation

All relevant clinical documentation must be submitted to support the medical necessity of the request. This includes, but is not limited to, applicable lab values, a treatment plan, and pertinent medical chart notes. Requests lacking required documentation may be delayed or denied.

Include lab results, treatment plan, and chart notes
Provide dosing consistent with FDA guidelines
If applicable, include documentation of prior therapies and responses

Denial Risk

Denial Risks for Non‑conforming Requests

Use of medications or dosing outside these guidelines, or failure to submit required documentation, may result in claim denial or non‑payment unless an exception is approved. Medicare members who received the same medication within the past 365 days may be exempt from step therapy requirements; verify member-specific rules.

Nonconforming requests (off‑guideline use or incorrect coding) risk denial
Failure to provide required documentation may cause denial
Medicare members with prior receipt within 365 days may not be subject to step therapy

Step Therapy Requirements

Step	Requirement	Coverage impact
1
Must try an available biosimilar product prior to coverage of the reference biologic unless the biosimilar is unavailable, or the patient has documented failure, intolerance, or a contraindication to the biosimilar.
covered_with_criteria
2
If no biosimilar exists, patient must have experienced inadequate response or intolerance to all first‑line agents (including generics where available) prior to coverage of the reference product.
covered_with_criteria
3
Medicare members who received the medication within the past 365 days are not subject to Step Therapy requirements for prior receipt within that window.
neutral

Biosimilar Preference and Reference Biologics

Billing Rule

Reference biologic requires biosimilar failure/intolerance/contraindication

If a biosimilar product exists, coverage of the reference biologic will only be provided after documentation shows the member had failure, intolerance, or a contraindication to the biosimilar product, unless biosimilars do not exist.

Provide documentation of failure, intolerance, or contraindication to the biosimilar when requesting the reference biologic
If biosimilars are unavailable, note that on the request

Definitions

inv-12: Medically accepted indication — FDA-approved indication or an indication supported by standard reference compendia (AHFS-DI, Thomson/Micromedex, Clinical Pharmacology...)

DefinitionAn FDA-approved indication or an indication supported by standard reference compendia (e.g., AHFS-DI, Thomson/Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs) or peer‑reviewed medical literature

Accepted compendia examplesAmerican Hospital Formulary Service information (AHFS-DI); Thomson/Micromedex DrugDex; Clinical Pharmacology; Wolters Kluwer Lexi-Drugs

Evidence standardPeer‑reviewed published medical literature indicating sufficient evidence to support use is considered acceptable

Use implicationTherapies used at a dose or for a condition not recognized in these compendia or literature are considered investigational and not covered