The policy lists specific product types and uses that are not covered under Neighborhood Health Plan of Rhode Island's pharmacy benefits for each line of business. For Medicaid, exclusions include: biological products for allergy immunizations and vaccinations, blood fractions, certain compounded medications, drugs dispensed outside Health Plan guidelines, drugs not proven effective per FDA, drugs used for cosmetic purposes, products from manufacturers not participating in the Medicaid Drug Rebate Program, experimental drugs (including DESI status), medications provided by institutions that include drug services, non-medical substances, off‑label use of drugs (unless mandated by law for cancer treatment), support garments and durable medical equipment (except diabetic testing supplies), therapeutic devices and appliances (with limited syringe/needle exceptions), medications for sexual/erectile dysfunction (ED), medical marijuana, and medications for infertility.
For Commercial members, excluded items include: any drug used for cosmetic purposes; experimental or investigational uses and off‑label use (unless legally required for cancer); ED medications; medical marijuana; compounded products without at least one legend drug; prescription and OTC homeopathic drugs; non‑drug prosthetic/therapeutic devices and supports (except diabetic testing supplies); drugs lacking or withdrawn FDA approval; prescriptions filled at non‑Neighborhood network retail pharmacies (except emergency care); prescription drugs once the same active ingredient is available OTC; prescription drugs packaged with non‑prescription products; and OTC drugs/products not on the formulary.
For Medicare members, the policy excludes medications for sexual/erectile dysfunction, infertility medications, medications used for indications that are not FDA‑approved or compendia‑supported, and medications used inconsistently with applicable National or Local Coverage Determinations.