CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prescription Drug Coverage in Assisted Living and Long-term Care Facilities

This document governs use of Neighborhood Health Plan formularies and prior authorization procedures for medications (including OTC and restricted drugs) for plan members residing in assisted living and long-term care facilities and informs providers and dispensing pharmacies about utilization management requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrescription Drug Coverage in Assisted Living and Long-term Care Facilities

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit a Prior Authorization request to Neighborhood for OTC or restricted medications for members in assisted living and long-term care facilities.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1document source chunk

OTC & restrictedPA-required meds

onlineformularies location

Coverage Criteria

No explicit coverage criteria are stated in the source document. The policy provides informational guidance about the expectation that provider partners use Neighborhood formularies and describes prior authorization requirements for over-the-counter (OTC) and utilization-managed medications for members in assisted living and long-term care facilities.

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Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required for over-the-counter (OTC) products and for any medication subject to Neighborhood's utilization management (UM) restrictions, including non-formulary or restricted drugs. Providers must obtain Prior Authorization before initiating or arranging dispensing of these medications for members residing in assisted living or long-term care facilities.

Applies to OTC drugs and medications with UM restrictions (including non-formulary and restricted agents).
Prior Authorization requests must be submitted to Neighborhood before dispensing or administration.

Note

Provider Responsibility — Submit PA When Requested

Providers and dispensing pharmacies serving members in assisted living or long-term care facilities are obligated to work with Neighborhood to secure approval. Pharmacies may request that the provider submit a Prior Authorization when a drug has a UM restriction or is OTC.

Provider and pharmacy coordination is required for PA submission.
Neighborhood's formularies should be used when creating treatment plans; current formularies are available on the Neighborhood website.

Note

How to Submit Prior Authorization

Submit Prior Authorization requests to Neighborhood for members in assisted living/long-term care when the requested medication is OTC or subject to utilization management.

Include clinical justification and relevant member information in the PA request.
Use Neighborhood's PA submission processes as outlined on the payer website or provider portal.

Denial Risk

Denial Risk if PA Not Obtained

If Prior Authorization is not obtained when required for OTC or UM-restricted medications, the claim or dispensing may be denied. Providers and pharmacies should secure approval in advance to avoid denial or non-payment.

Denials or payment disputes may result if PA is not approved prior to dispensing.
Confirm PA approval before placing overrides or dispensing medication.

Background

Neighborhood expects provider partners to utilize Neighborhood drug formularies when creating drug treatment plans for members residing in assisted living and long-term care facilities to ensure safe and cost-effective treatment options. The policy notes that the most up-to-date formularies are available on Neighborhood’s website by line of business. When a member requires an over-the-counter (OTC) medication or a medication that has a utilization management (UM) restriction (including non‑formulary and OTC drugs), providers must work with Neighborhood and submit a Prior Authorization request; dispensing pharmacies may also request that a provider submit a Prior Authorization to place an override and dispense the medication.

Definitions

utilization management (UM) restriction — definition and actions

DefinitionUtilization management (UM) restriction: any formulary-based restriction that may require prior authorization, step therapy, or other management prior to coverage/dispensing.

ScopeApplies to formulary restrictions including non-formulary drugs and over-the-counter (OTC) medications for members in assisted living and long-term care facilities.

Provider actionProviders must work with Neighborhood to obtain approval by submitting a Prior Authorization when a medication has a UM restriction.

Pharmacy actionDispensing pharmacies may request that providers submit a Prior Authorization to place an override and dispense medications with a UM restriction.

Location of formulariesThe most up-to-date versions of Neighborhood formularies are listed by line of business on the Neighborhood website.