CurrentNeighborhood Health Plan of Rhode IslandPolicy 000826

Benefit Exclusion

Defines medications and medication-related products that Neighborhood Health Plan of Rhode Island does not cover across Medicaid, Commercial, and INTEGRITY (Medicare‑Medicaid) benefits and explains where exclusions apply (pharmacy vs buy-and-bill/medical).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBenefit Exclusion

Policy CodePolicy 000826

Change TypeNo material change

Effective DateJul 26, 2019

Next Review Date

Key ActionDo not submit prior authorization requests for items explicitly listed as Benefit Exclusions; those items are not eligible for coverage under the applicable benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicaid, Commercial, INTEGRITYLines of business in scope

MultipleDocument reviews

Benefit ExclusionPolicy type

ManyExclusion categories

Benefit Exclusions (by benefit/service type)

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Pharmacy benefit exclusions (selected items)

Allergy and vaccine exclusions: Biological products for allergy immunizations; Biological products for vaccinations
Blood and blood products: Blood fractions
Compounded and regulatory exclusions: Compound medications that are not made up of at least one legend drug; Drugs that have not been proven effective according to the FDA; Drugs whose manufacturer does not participate in the Medicaid Rebate Program (MDRP); Drugs prescribed or dispensed outside of Health Plan dispensing guidelines; Drugs not lawfully marketed without FDA approval
Cosmetic and experimental: Drugs used for cosmetic purposes; Experimental drugs (including DESI/notice of opportunity hearing status)
Therapeutic devices and DME exclusions: Therapeutic devices and appliances, supports and other non-drug products (except diabetic supplies); Support garments and other durable medical equipment (except for diabetic supplies)
Off-label and cancer-mandate carve-out: Off-label use of drugs unless mandated by laws pertaining to the treatment of cancer
Sexual dysfunction and infertility: Medications prescribed for the treatment of sexual or erectile dysfunction (ED); Medications for infertility treatment
Medical marijuana
Travel-related exclusions: Travel medications used to prevent diseases associated with travel to foreign countries (e.g., malaria, typhoid) and travel vaccines for diseases not commonly encountered in the U.S. are not covered when obtained at a pharmacy (travel vaccines recommended by ACIP are covered for Medicaid members)
Institutional dispensing: Medications an enrollee may take or was given while residing in an institution that provides prescription drugs as part of its services or operates its own dispensing facility
Administration supplies exclusion: Hypodermic needles and syringes (except when used to administer insulin or for self-administration of FDA-approved injectable drugs)

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Medical (buy-and-bill) Benefit Exclusions

The following are considered Benefit Exclusions and are therefore not covered by Neighborhood's Medicaid Benefit when billed directly by a provider (buy-and-bill or Medical Benefit):

Medical (buy-and-bill) exclusions (selected items)

Cosmetic and experimental: Products used for cosmetic purposes; Experimental products or products used experimentally (unless cancer-mandated)
Regulatory/manufacturer: Drugs or products whose manufacturer does not participate in the Medicaid Rebate Program (MDRP)
Sexual dysfunction and infertility: Medications prescribed for infertility treatment and sexual or erectile dysfunction (ED)
Medical marijuana
Travel-related and off-label: Travel medications used to prevent diseases associated with travel to foreign countries are not covered; Off-label use of drugs is not covered unless mandated by laws pertaining to the treatment of cancer

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Commercial and INTEGRITY Benefit Exclusions

The following are considered Benefit Exclusions and therefore not covered by Neighborhood's Commercial Benefit and INTEGRITY (Medicare‑Medicaid) Benefit (selected items):

Commercial benefit exclusions (selected items): Products used for cosmetic purposes; Experimental products; Off-label drug use (unless cancer-mandated); Medications prescribed for sexual and erectile dysfunction; Medical marijuana; Compounded products lacking a legend drug; Non-drug therapeutic devices/appliances/supports (except diabetic testing supplies); Prescription and OTC homeopathic drugs; OTC products not on formulary; Prescriptions filled at non-network pharmacies (except emergency care); Prescription drugs once same active ingredient available OTC; Continuous Glucose Monitors that do not meet CMS' definition of a therapeutic CGM for INTEGRITY members

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This policy enumerates categories of medications and medication-related products that are excluded from coverage under Neighborhood’s benefits. Excluded categories include, but are not limited to: drugs used for cosmetic purposes; experimental products or products used experimentally (unless coverage is mandated by law for cancer treatment); medications prescribed for infertility; medications prescribed for sexual or erectile dysfunction (ED); medical marijuana; compound medications that do not contain at least one legend drug; blood fractions; certain biologicals (allergy immunizations and some vaccination biologicals); and therapeutic devices, appliances, and non-drug prosthetics (except diabetic testing supplies).

The exclusions listed apply by benefit and site of care: items identified as pharmacy benefit exclusions are not covered when obtained at a pharmacy, and items listed as medical (buy-and-bill) exclusions are not covered when billed under the medical benefit. Off‑label use is generally not covered unless explicitly mandated for cancer treatment or supported by applicable compendia or law. Products excluded because the manufacturer does not participate in the Medicaid Rebate Program are also not covered. For reference, these Benefit Exclusions are reflected in member and provider materials such as the Medicaid Member Handbook, Commercial Certificate of Coverage, and the Provider Manual; excluded items are not eligible for prior authorization and claims for excluded items will be denied under the applicable benefit.

Provider Impact, Billing and Authorization

Prior Authorization

Excluded items not eligible for prior authorization

Excluded items listed in this policy are not eligible for prior authorization. Providers should not submit prior authorization requests for medications or products that are identified as Benefit Exclusions under Neighborhood Health Plan of Rhode Island. Requests for excluded items will not be approved and will be processed as not covered.

Excluded items are not PA-eligible and cannot be authorized under either the pharmacy or medical benefit
Refer to Member Handbook, Certificate of Coverage, and Provider Manual for the full exclusions list

Denial Risk

Medical benefit denials

Drugs and products considered Benefit Exclusions will be denied when billed under the medical (buy-and-bill) benefit. When a provider bills these excluded items on a medical claim, the claim will be processed as not covered and will be denied. Examples include but are not limited to: medications for sexual or erectile dysfunction, medical marijuana, experimental products, compounded products not containing at least one legend drug, infertility treatments, and products from manufacturers not participating in the Medicaid Rebate Program.

Medical benefit denials apply to buy-and-bill/provider-administered products that are listed as Benefit Exclusions
Providers should not bill excluded products under the medical benefit expecting coverage
If an excluded item is billed under medical benefit it will be denied as not covered

Denial Risk

Pharmacy benefit denials

Claims for excluded items obtained at a pharmacy will be denied/not covered under the pharmacy benefit. Pharmacy claims for items listed as Benefit Exclusions will be processed as not covered and will not be reimbursed.

Pharmacy benefit denials apply to excluded items dispensed at retail or network pharmacies
Examples include travel vaccines/medications not covered for travel-related disease prevention, cosmetic-use drugs, and other excluded categories listed in the policy

Note

Reference documents

The Benefit Exclusions listed in this policy are also referenced in the Medicaid Member Handbook, the Commercial Certificate of Coverage, and the Provider Manual. Providers should cross-reference those documents for member-specific coverage details and any updates.

Member Handbook, Certificate of Coverage, and Provider Manual contain corresponding exclusions and are updated periodically

Step Therapy

Step therapy

The exclusions list does not establish step therapy requirements. Listing an item as excluded is not equivalent to creating a step therapy pathway.

Excluded items are simply not covered; they do not form or imply step therapy requirements

Policy Background

This policy covers exclusions across Neighborhood’s lines of business — Medicaid, Commercial, and INTEGRITY (Medicare‑Medicaid) — and specifies where exclusions apply by site of care (pharmacy vs. medical/buy‑and‑bill). Medication categories and situations not covered across lines of business include: cosmetic products; experimental or investigational uses (except cancer‑mandated uses); infertility and ED medications; medical marijuana; compounds lacking a legend drug; non-drug devices/appliances (except diabetic testing supplies); OTC/homeopathic products unless on the formulary; prescriptions filled at non‑network pharmacies except emergency care; and medications not FDA‑approved or not supported by compendia (including certain travel vaccines/medications). INTEGRITY members have the additional specification that continuous glucose monitors not meeting CMS’ therapeutic CGM definition are excluded.

Key Definitions

Benefit Exclusion — definition of a medication or medication-related product that Neighborhood does not cover under the specified benefit

DefinitionA medication or medication-related product that Neighborhood does not cover under the specified benefit (pharmacy or medical) as enumerated in this policy.

When it appliesApplies to items listed as Benefit Exclusions when obtained at a pharmacy (pharmacy benefit) or when billed directly by a provider (buy-and-bill/medical benefit).

Examples of excluded items (pharmacy)Biological products for allergy immunizations and vaccinations; blood fractions; compounded products lacking at least one legend drug; drugs not proven effective by the FDA; drugs used for cosmetic purposes; experimental drugs; off‑label use (unless cancer‑mandated); medications for infertility and sexual/erectile dysfunction; medical marijuana; certain travel vaccines and travel medications.

Examples of excluded items (medical/buy-and-bill)Products used for cosmetic purposes; experimental products; drugs from manufacturers not participating in the Medicaid Rebate Program; medications for infertility and sexual/erectile dysfunction; medical marijuana; travel vaccines and travel medications; off‑label drug use (unless cancer‑mandated).

Prior authorization and claims impactItems identified as Benefit Exclusions are not eligible for prior authorization under the applicable benefit and will be denied/not covered when billed under the non‑applicable benefit (e.g., pharmacy fills denied under Medicaid pharmacy benefit; excluded drugs billed under medical benefit not covered).

Coverage by Site of Care

Note

Coverage varies by benefit and site of care

Coverage for items in this policy varies by benefit and site of care: items listed as excluded apply when obtained at a pharmacy (pharmacy benefit) and/or when billed under the medical/buy-and-bill benefit; non‑network pharmacy fills are not covered except for emergency care.

Exclusions apply differently depending on whether the item is dispensed at a pharmacy or billed under medical (buy-and-bill).
Non-network pharmacy fills are excluded except in emergency situations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBenefit Exclusion

Policy CodePolicy 000826

Change TypeNo material change

Effective DateJul 26, 2019

Next Review Date

Key ActionDo not submit prior authorization requests for items explicitly listed as Benefit Exclusions; those items are not eligible for coverage under the applicable benefit.

SourceLink

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