CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior Authorization for Non-Formulary and Restricted Drugs in Assisted and Long-Term Care

Describes expectation that providers and dispensing pharmacies for Neighborhood Health Plan of Rhode Island members in assisted and long-term care facilities use Neighborhood formularies and obtain prior authorization for non-formulary or restricted medications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior Authorization for Non-Formulary and Restricted Drugs in Assisted and Long-Term Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a Prior Authorization when a required drug is non-formulary or has a restriction for members in assisted or long-term care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1document source chunk(s)

assisted & long-term caresettings referenced

PA requiredaction emphasized

Coverage Criteria

None specified in the document.

Provider Actions and Requirements

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior Authorization for Non-Formulary and Restricted Drugs in Assisted and Long-Term Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a Prior Authorization when a required drug is non-formulary or has a restriction for members in assisted or long-term care.

SourceLink

On This Page

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Prior Authorization

Prior Authorization Required

Prior Authorization Required — Providers must use Neighborhood Health Plan of Rhode Island formularies when developing drug treatment plans for members residing in assisted living and long‑term care facilities. If a required drug is not on the member's formulary, is a restricted formulary drug, or is a non‑formulary over‑the‑counter (OTC) product, the provider must obtain Prior Authorization from Neighborhood before the medication is dispensed.

Applicable to non‑formulary drugs
Includes restricted formulary drugs and non‑formulary OTCs

Note

Provider/Pharmacy Coordination Required

Providers and dispensing pharmacies should coordinate: pharmacies may request that the provider submit a Prior Authorization when a drug has a utilization management restriction (including non‑formulary and OTC drugs). Failure to obtain required Prior Authorization may delay care and result in denial of payment.

Pharmacies may request provider‑submitted Prior Authorization to place an override and dispense
Coordination is required for members in assisted and long‑term care settings

Prior Authorization

How to Submit a Prior Authorization

To obtain approval for drugs not on a member's formulary (including non‑formulary OTCs and restricted drugs), providers must submit a Prior Authorization request to Neighborhood Health Plan of Rhode Island following Neighborhood’s submission procedures. Work with the member’s pharmacy and Neighborhood’s UM team to ensure all required documentation is provided.

Submit Prior Authorization via Neighborhood’s specified process
Include clinical justification and relevant supporting documentation
Coordinate with the dispensing pharmacy as needed

Denial Risk

Risk of Denial Without Prior Authorization

Risk of Denial — If a Prior Authorization is not submitted and approved for non‑formulary drugs, restricted formulary drugs, or non‑formulary OTC medications for assisted/long‑term care members, claims may be denied and members may experience delays in receiving medications.

Denial risk applies to non‑formulary, restricted formulary, and non‑formulary OTC drugs
Particularly enforced for members in assisted living and long‑term care facilities

Background

Neighborhood expects provider partners to utilize Neighborhood drug formularies when creating drug treatment plans for members residing in assisted and long-term care facilities to ensure safe and cost-effective treatment options. The most up-to-date formularies are published on Neighborhood’s website.

If a required drug is not on the member’s formulary, including a non-formulary over-the-counter (OTC) product, or if the medication has a restriction, providers must work with Neighborhood to obtain approval by submitting a Prior Authorization. Dispensing pharmacies serving assisted and long-term care members may also request providers submit a Prior Authorization for drugs subject to utilization management restrictions before placing an override and dispensing.

Definitions

Prior Authorization

DefinitionPrior Authorization: approval obtained from Neighborhood before dispensing certain non-formulary or restricted medications.

When requiredRequired for drugs not on the member's formulary and for formulary medications that have a restriction.

Who must obtain itProviders must work with Neighborhood to submit the Prior Authorization when a needed drug is non-formulary or restricted.

Pharmacy roleDispensing pharmacies may request that providers submit a Prior Authorization for medications with utilization management restrictions before placing an override and dispensing.

Non-formulary OTC

DefinitionNon-formulary OTC: an over-the-counter medication not listed on the member's respective formulary that requires authorization.

Authorization requirementProviders must submit a Prior Authorization to obtain approval for non-formulary OTCs needed by members in assisted and long-term care.

Dispensing guidancePharmacies may request a Prior Authorization for non-formulary OTCs that have utilization management restrictions prior to dispensing.