CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medications Covered under the Pharmacy Benefit Only

Defines which medications are covered exclusively under the pharmacy benefit for commercial members and describes prior authorization coverage and member notification when benefit changes occur.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedications Covered under the Pharmacy Benefit Only

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document required clinical criteria for pharmacy benefit coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1drugs listed

60 daysmember notice

180 dayslookback

Commercialscope

Coverage Criteria

Initial coverage

Covered when medication is on the pharmacy-only list and prior authorization clinical criteria are met.

Pharmacy-only coverage: Medication is listed as covered exclusively on the Pharmacy Benefit (for example, Hemlibra [emicizumab]) AND prior authorization is obtained with required clinical criteria documented

Medications not listed are not affected by this policy statement.

Initial Therapy Criteria

Hemlibra (emicizumab)

Drugs listed are covered under the pharmacy benefit with prior authorization when clinical criteria are met.

Hemlibra coverage: Hemlibra (emicizumab) is covered exclusively on the Pharmacy Benefit and requires prior authorization per pharmacy clinical criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedications Covered under the Pharmacy Benefit Only

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document required clinical criteria for pharmacy benefit coverage.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Prior Authorization

Prior Authorization

Pharmacy prior authorization required

The medications listed are covered with prior authorization under the pharmacy benefit when clinical criteria are met.

Note

Documentation Required

Documentation for PA

Members and providers will receive a 60-day advance notification of the change in benefit coverage if the member has obtained the medication under the medical benefit within the previous 180 days.

Prior Authorization

Prior authorization required

Coverage for the listed medications is available with prior authorization when clinical criteria are met; lack of prior authorization may trigger denial or conversion of the claim from the medical benefit to the pharmacy benefit.

Definitions

Pharmacy-benefit-only medications — definition and sourcing guidance

DefinitionMedications listed as 'covered and available exclusively on the Pharmacy Benefit' must be obtained through the pharmacy benefit and are subject to pharmacy prior authorization when clinical criteria are met.

Prior authorizationListed pharmacy‑benefit‑only medications are covered with prior authorization when clinical criteria are met.

Member notification for benefit changesMembers who received the medication under the medical benefit within the prior 180 days will receive a 60‑day advance notification of the change in benefit coverage.

ScopeThis policy identifies medications that are only covered through the member's pharmacy benefit (applies to commercial members per policy scope).

OpenPayer

Medications Covered under the Pharmacy Benefit Only

Coverage Criteria

Initial Therapy Criteria

Provider Actions and Prior Authorization

Definitions

Background