CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

2026 Commercial Formulary Foreword 2

Describes Neighborhood Health Plan of Rhode Island's Commercial pharmacy formulary purpose, maintenance by the P&T committee, how drugs are listed and classified (PA, QL, ST, OTC, C), general coverage limitations (outpatient only, exclusions), generic substitution and therapeutic interchange policies, exception/prior authorization/step therapy/adverse determination processes, and contact/appeal channels.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policy2026 Commercial Formulary Foreword 2

Policy CodePolicy N/A

Change TypeInformational foreword

Effective DateN/A

Next Review DateN/A

Key ActionFor PA-listed drugs prescriber or representative must fax completed PA request to 1-866-423-0945 or call 1-401-427-8200 and provide required information; requests reviewed per PBM P&T criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this foreword.

PA, QL, ST, OTC, CKey Formulary Flags

QuarterlyP&T Meeting Frequency

Outpatient onlyScope

Policy Overview

Purpose: This foreword explains the rationale and operational processes for the Neighborhood Health Plan of Rhode Island Commercial pharmacy formulary, including how the formulary is defined, maintained, and how stakeholders may request changes or appeal Non-Formulary and restricted medication decisions.

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Factors considered by the P&T Committee: Safety, Efficacy (potential effects under optimal circumstances), Effectiveness (actual effects in real life), relevant benefits of current formulary agents of similar use, Cost and outcome modeling, potential duplication of similar drugs, any necessary restrictions to assure safe/effective use, and requirements/restrictions set forth in the Commercial Benefit Contract.

How to request changes or exceptions: Prescribers, pharmacists, and members are encouraged to submit input, suggestions, or requests to the P&T Committee (Chair, Pharmacy & Therapeutics Committee, Neighborhood Health Plan of Rhode Island, 910 Douglas Pike, Smithfield, RI 02917). For coverage exceptions or Non-Formulary requests, prescribers must follow the Exception and Prior Authorization processes (see Prior Authorization, Step Therapy, and Exception Process sections) and may contact Neighborhood Pharmacy Department or Customer Service as directed in the formulary.

Scope summary: Describes Neighborhood Health Plan of Rhode Island's Commercial pharmacy formulary purpose, maintenance by the P&T Committee, how drugs are listed and classified (PA, QL, ST, OTC, C), general coverage limitations (outpatient drugs only, exclusions such as cosmetic or experimental uses), policies on generic substitution and therapeutic interchange, and the exception/prior authorization/step therapy/adverse determination processes with contact and appeal channels.

Coverage Provisions

General Formulary Coverage Provisions

The following general provisions pertain to all covered individuals:

ALL of the following

Some Over The Counter (OTC) products are covered for members; a written prescription is required for OTC products.
Drug Products not listed in the Formulary at www.nhpri.org are not covered.
Any drug products used for cosmetic purposes are not covered.
Experimental drug products, or any drug products used in an experimental or off-label manner are not covered.
Replacement of lost or stolen medications will be covered on a case-by-case basis.
Drug products failing industry-standard patient safety screens will not be dispensed at the pharmacy without further information from the prescriber.

Prior Authorization

Covered when PA-listed drugs require approval:

ALL of the following

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

Step Therapy

Coverage for ST-listed drugs:

ALL of the following

Member must try required formulary products prior to initiating the requested medication.
Provider can request an exception to Step Therapy if formulary alternatives are not appropriate or there is a reason the member cannot take the alternatives.

Exception Process for Non-Formulary Medications

Requests for Non-Formulary medications may be applied for by prescribers; prescriber must provide information addressing at least one of the following:

ONE of

The use of Formulary products is contraindicated in the patient.
The patient has failed an appropriate trial of Formulary or related agents.
The choices available in the Drug Formulary are not suited for the present patient care need, and the drug selected is required for patient safety.
The use of a Formulary Drug may provoke an underlying condition, which would be detrimental to patient care.

Adverse Determination / Denial Process

When requests do not meet benefit exception criteria:

ALL of the following

Rationale and Formulary alternatives will be provided to the prescribing provider.
Prescriber may be referred to Neighborhood Medical Director or Physician Reviewer for approval or denial; Medical Director/Reviewer will assess medical necessity after discussion.
In event of denial the Medical Director/Reviewer will discuss reasons with prescriber, provide written letters to prescriber and member documenting reasons, applicable benefit or clinical guideline, appeal process and how to review documentation.
Members may register an inquiry or complaint with Customer Service to be responded to with standard response protocols and notification of appeal rights.

Therapeutic Interchange

Therapeutic interchange may be performed with prescriber's approval when clinically appropriate:

ALL of the following

Neighborhood Pharmacy staff will contact prescriber's office if it is determined a therapeutic interchange is appropriate.
Interchanged medications are expected to produce similar clinical effectiveness and outcomes based on available evidence.

Generic Substitution

Policy for generic use:

ALL of the following

When available, FDA approved generic drugs are to be used in all situations; all drugs that are or become available generically are subject to review by the PBM's P&T Committee.

Actions for Providers

Prior Authorization

Prior Authorization Required

Prior Authorization (PA) is required for drugs designated 'PA' in the Formulary. To obtain coverage, a prescriber or prescriber's representative may fax a completed Prior Authorization Request to the Neighborhood Pharmacy Department at 1-866-423-0945 or contact the Neighborhood Pharmacy Department by phone 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 Pharmacy Benefit Manager's (PBM's) P&T Committee.

Codes: PA
Fax: 1-866-423-0945
Phone: 1-401-427-8200
Requests reviewed per PBM P&T Committee criteria

Step Therapy

Step Therapy Exception

Step Therapy (ST) requires that specified formulary alternatives be tried prior to coverage of the requested medication. If the required formulary products are inappropriate for the member or there is a clinical reason the member cannot take the formulary alternatives, the provider may request an exception to the Step Therapy requirement.

Codes: ST
Provider may request exception when formulary alternatives are inappropriate

Documentation Required

Non‑Formulary Exception Documentation

When requesting a Non‑Formulary exception, prescribers should document why formulary alternatives are not appropriate for the patient. Required information includes clinical justification showing one or more of the following: contraindication to formulary products; failure of an appropriate trial of formulary or related agents; formulary choices are not suited to the patient’s care needs and the requested drug is required for patient safety; or use of a formulary drug may provoke an underlying condition detrimental to patient care.

Document contraindications to Formulary products
Document failed trials of appropriate Formulary or related agents
Explain why Formulary choices are not suited for the patient's care needs and why the requested drug is required for patient safety
Document risk that use of a Formulary drug would provoke an underlying condition detrimental to patient care

Denial Risk

Adverse Determination and Appeal Procedures

If a request does not meet exception criteria, Neighborhood will communicate the rationale and Formulary alternatives to the prescribing provider. The prescriber may be referred to the Neighborhood Medical Director or Physician Reviewer for clinical review. If the Medical Director or Physician Reviewer denies the request, they will discuss the reason for denial with the prescriber and provide written notice to both the prescriber and the member describing the decision, the applicable benefit or clinical guideline, and information on how to appeal.

Expected communications when denied: rationale and Formulary alternatives provided to prescriber
Medical Director/Physician Reviewer will review and discuss with prescriber
Written notices to prescriber and member documenting reasons for decision, applicable guideline, and appeal instructions
Members may contact Customer Service (1-855-321-9244) to register inquiries or complaints and receive appeal rights information

Definitions

Therapeutic Interchange: Replacing a prescribed medication with a chemically different medication expected to have similar clinical effectiveness, done with the prescribing physician's approval; Neighborhood Pharmacy staff will contact the prescriber's office when an interchange is appropriate.

Step Therapy (ST): Requirement to try specified formulary alternatives prior to coverage of the requested medication; providers may request an exception if required formulary alternatives are inappropriate or cannot be taken.

Prior Authorization (PA): Process whereby PA-listed drugs require approval from the Neighborhood Pharmacy Department prior to coverage; prescribers or their representatives may fax a completed Prior Authorization Request to 1-866-423-0945 or call 1-401-427-8200 to provide required information.

Quantity Limit (QL): A limit on the quantity of medication that can be dispensed per the formulary's Requirements/Limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policy2026 Commercial Formulary Foreword 2

Policy CodePolicy N/A

Change TypeInformational foreword

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

PA	Prior Authorization required
QL	Quantity Limit applied
ST	Step Therapy required
OTC	Over The Counter product
C	Can be dispensed at retail pharmacy for up to 365 days' supply in one fill

OpenPayer

2026 Commercial Formulary Foreword 2

Policy Overview

Coverage Provisions

Formulary Labels and Codes

Actions for Providers

Definitions

Revision History