CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Commercial Drug Formulary — Coverage Criteria and Utilization Management

Defines the covered outpatient prescription drugs, formulary structure, utilization management (prior authorization, step therapy, quantity limits), and exception/appeal processes for Neighborhood Health Plan of Rhode Island Commercial members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCommercial Drug Formulary — Coverage Criteria and Utilization Management

Policy CodePolicy N/A

Change TypeNo material changes in this revision

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionPrescribers must submit a completed Prior Authorization request by fax (1-866-423-0945) or phone to the Neighborhood Pharmacy Department and provide supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

QuarterlyP&T meetings

Outpatient onlyScope

PA/ST/QLUM flags

PBM/P&T (8)Selection criteria

Coverage Criteria and Exceptions

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Exception / Prior Authorization Criteria

Coverage of non-formulary or restricted drugs requires meeting one of the following exception criteria and completion of required authorization processes.

Exception bases

Formulary products are contraindicated for the patient.
The patient has failed an appropriate trial of formulary or related agents.
Formulary choices are not suited for the present patient care need and the requested drug is required for patient safety.
Use of a formulary drug may provoke an underlying condition detrimental to patient care.

ALL of the following

If the drug is designated 'PA', the prescriber or representative must fax a completed Prior Authorization Request to Neighborhood Pharmacy Department at 1-866-423-0945 or contact the Neighborhood Pharmacy Department at 1-401-427-8200 and provide all necessary clinical information for review.
Each PA request will be reviewed based on individual patient need and criteria approved by the PBM's P&T Committee.

ALL of the following

If the drug is designated 'ST', the member must have trialed the specified formulary alternatives prior to coverage of the requested medication unless an exception is granted.
Provider may request an exception to Step Therapy if required formulary alternatives are inappropriate for the member.

ALL of the following

Requests that do not meet the criteria for a benefit exception may be denied after review by Neighborhood medical staff or the Medical Director/Physician Reviewer.
Written notices with the rationale and appeal rights will be provided to the member when a request is denied.

The Formulary applies only to outpatient prescription drugs; medications used in inpatient settings are excluded. Drugs that are not listed in the Formulary are not covered. In addition, any drug products used for cosmetic purposes are excluded. Coverage of non-formulary or restricted drugs may be considered only through the exception/prior authorization process when the prescriber documents clinical justification per PBM requirements.

Determinations about whether a drug or a specific use is experimental are made by the PBM's Pharmacy & Therapeutics (P&T) Committee using current medical literature. Any drug product or use that the P&T Committee classifies as experimental — including off‑label uses deemed experimental — will be excluded from coverage.

Provider Requirements, Authorization, and Denials

Prior Authorization

Prior Authorization Required

Drugs listed with 'PA' require Prior Authorization and must be reviewed and approved before coverage. To obtain coverage the prescriber or prescriber's representative must either fax a completed Prior Authorization Request to the Neighborhood Pharmacy Department at 1-866-423-0945 or contact the Neighborhood Pharmacy Department pharmacist at 1-401-427-8200 and provide all necessary information. Each request is reviewed on individual patient need and according to criteria approved by the PBM's P&T Committee.

Fax Prior Authorization Request: 1-866-423-0945
Phone Neighborhood Pharmacy Department: 1-401-427-8200
Requests reviewed per PBM P&T Committee criteria

Step Therapy

Step Therapy Requirement

Drugs listed with 'ST' require step therapy, meaning the member must try specified formulary alternatives before the requested medication will be covered. If required formulary alternatives are inappropriate for the member or the member cannot take them, the provider may request an exception to the Step Therapy requirement.

Provider may request a Step Therapy exception when alternatives are inappropriate

Documentation Required

Prior Authorization Request and Required Information

If a prescriber wishes to request coverage for a non‑formulary medication or an exception (including step therapy exceptions), the prescriber or prescriber's representative should call or fax a completed Prior Authorization Request (fax to 1-866-423-0945) or contact the Neighborhood Pharmacy Department pharmacist at 1-401-427-8200 and provide clinical information to support the request. For non‑formulary or exception requests, be prepared to document that: a) formulary products are contraindicated; b) the patient has failed an appropriate trial of formulary or related agents; c) formulary choices are not suited for the present patient care need and the selected drug is required for patient safety; or d) use of a formulary drug may provoke an underlying condition detrimental to patient care.

Fax Prior Authorization Request: 1-866-423-0945
Phone Neighborhood Pharmacy Department: 1-401-427-8200
Document clinical rationale addressing contraindication, prior trials, safety need, or risk of provoked condition

Denial Risk

Denial Process and Notification

When a request does not meet criteria for a benefit exception, Neighborhood will provide the prescribing provider with the rationale and formulary alternatives. If the prescriber contests the alternatives, the case will be referred to the Neighborhood Medical Director or Physician Reviewer, who will assess medical necessity and approve or deny the request. If denied, the Medical Director or Physician Reviewer will discuss the reason for denial with the prescriber, explain appeal rights, and send written notification to both prescriber and member documenting the reasons for the decision, applicable benefit or clinical guideline, and information on how to file an appeal. Members may also register an inquiry or complaint with Customer Service to receive standard response protocols and notification of appeal rights.

Rationale and formulary alternatives provided to prescriber when request does not meet exception criteria
Referral to Medical Director/Physician Reviewer for contested cases
Written denial letters to prescriber and member outlining reasons, guidelines, and appeal process
Members can register inquiries/complaints with Customer Service

Key Terms and Flags

ST (Step Therapy)

DefinitionCoverage only after trial/failure of specified formulary products; exceptions may be requested.

RequirementMember must have trial/failure of required formulary alternatives unless an exception is granted.

Provider actionPrescriber may request an exception via Prior Authorization when required alternatives are inappropriate for the member.

PA (Prior Authorization)

DefinitionDrugs that require approval from Neighborhood/PBM before coverage is provided.

Provider actionPrescribers must submit a Prior Authorization request by fax or phone and provide clinical information per PBM/P&T criteria.

OutcomeCoverage is provided only after review and approval of the PA request.

QL (Quantity Limit)

DefinitionA limit on the quantity of medication that can be dispensed per fill or time period.

Formulary displayDrugs listed as 'QL' in the Formulary indicate a quantity limit applies.

PurposeUsed to manage appropriate use and dosing frequency for specific agents.

OpenPayer

Commercial Drug Formulary — Coverage Criteria and Utilization Management

Coverage Criteria and Exceptions

Provider Requirements, Authorization, and Denials

Formulary Governance and Rationale

Key Terms and Flags

Step Therapy Details

Quantity Limit Policies