CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid Medical Benefit Only Policy

Defines pharmaceutical products that are covered exclusively through the member's medical benefit (administered in clinician office, outpatient setting, or by home infusion) for Medicaid members. Notes that products may be authorization required and that members receive 60-day notice if benefit changes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Medical Benefit Only Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review Date

Key ActionObtain prior authorization when required and document medical necessity before administering products listed as medical benefit only.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or benefit structure.

23Listed Products Covered on Medical Benefit

Coverage Summary

This policy defines pharmaceutical products that are covered exclusively on the Medicaid Medical Benefit when medically necessary. Products listed may be Authorization Required (prior authorization). If a medication's benefit changes from the pharmacy to the medical benefit and the member obtained the medication under the pharmacy benefit within the prior 180 days, the member and provider will receive a 60-day advance notification of the change. Effective: 2020-01-01. Last review: 2026-03-01.

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.

Medical-Benefit-Only Coverage Criteria

Medical-Benefit-Only Coverage List

The following pharmaceutical products are available exclusively on the Medical Benefit when medically necessary:

ALL of the following

Intravenous (IV) Infliximab Products
Hyaluronic Acid Products
Immune Globulin Agents (Intravenous and Subcutaneous)
Provider-administered contraceptives such as intrauterine devices (e.g., Mirena, Skyla, Kyleena, etc.) or subdermal implants (e.g. Nexplanon)
Krystexxa
Cinqair
Xiaflex
Long-Acting Granulocyte Colony Stimulating Factors: Fulphila, Fylnetra, Neulasta, Neulasta Onpro, Nyvepria, Rolvedon, Stimufend, Udenyca, Ziextenzo
Givlaari
Tysabri
Ocrevus
Naglazyme
Simponi Aria
Cimzia
Somatuline Depot
Rituxan (rituximab) and biosimilars (e.g., Truxima, Riabni, Ruxience)
Berinert
Trelstar
Hemophilia Products
- Factor Anti-Inhibitor Coagulant Complex: Feiba NF/VF
- Factor VIIa: Novoseven RT, Sevenfact
- Factor X: Coagadex
- Factor_XIII: Corifact
- Factor_XIIIA-subunit: Tretten

General Conditions

Operational and notification conditions

ALL of the following

Medications are covered on the Medical Benefit when medically necessary.
Products may be Authorization Required (prior authorization).
Members and providers will receive a 60-day advance notification of change in benefit coverage if the member has obtained the medication under the pharmacy benefit within the previous 180 days.

Provider Actions & Requirements

Prior Authorization

Authorization may be required

Products listed may be Authorization Required; obtain prior authorization per payer procedures before administration if required.

Documentation Required

Medical necessity documentation

Document medical necessity supporting administration in clinician office, outpatient setting, or by home infusion therapy provider as the medication is covered on the medical benefit when medically necessary.

Billing Rule

Benefit change notification

If a medication's benefit changes from pharmacy to medical and the member obtained the medication under pharmacy benefit within prior 180 days, provide 60-day advance notification to member and provider.

Definitions & Background

Medications are billed under the medical benefit because they are administered in a clinician's office, outpatient setting, or by a home infusion therapy provider (for example IV, injection, implant, or infusion). Medical necessity must be documented and some products may require prior authorization before administration.

Medical BenefitCoverage for medications administered in a clinician's office, outpatient setting, or by a home infusion therapy provider rather than through the pharmacy benefit.