CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Neighborhood Health Plan of Rhode Island Formulary (Medicaid)

Defines the outpatient pharmacy formulary for Neighborhood Health Plan of Rhode Island Medicaid members, including coverage rules, prior authorization, step therapy, and exception processes for prescribers, pharmacists, and members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNeighborhood Health Plan of Rhode Island Formulary (Medicaid)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescribers must obtain prior authorization (PA) for drugs listed as PA by faxing a completed PA request to Neighborhood Pharmacy or contacting the Pharmacy Department for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyP&T Committee meeting frequency

outpatient onlyFormulary applies to

one monthDefault dispensed quantity limit

prior authorizationSome drugs require PA

Coverage and Medical Necessity Criteria

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Formulary coverage and exception criteria

Covered when ALL of the following are met

Formulary Coverage Preconditions: Drug is an outpatient prescription listed on the Neighborhood Formulary and not otherwise excluded; dispensed quantity adheres to stated limits (generally one month's supply).one month's supply

Baseline coverage conditions from Formulary document

Exception for Non-Formulary Coverage

Contraindication to Formulary products: The use of Formulary products is contraindicated in the patient.
Provider must document contraindication
Therapeutic Failure: The patient has failed an appropriate trial of Formulary or related agents.
Prescriber must provide trial history
Patient safety / clinical necessity: Available formulary choices are not suited for the patient's clinical need and the requested drug is required for patient safety.
Prescriber must justify safety need

Documentation and Request Process: Prescriber must request coverage for Non-Formulary medications by calling or faxing Neighborhood pharmacy and provide clinical information addressing contraindications, prior trials, or safety rationale as part of the exception request.

Pharmacy will evaluate and coordinate with medical staff

The Formulary applies only to outpatient drugs provided to members; inpatient medications are not covered under this document. Drug products not listed in the Formulary are not covered. In addition, the following general exclusions apply: cosmetic uses, infertility treatments, experimental or off‑label uses, and products failing industry standard patient safety screens. Unless otherwise stated, dispensed quantities are limited to one month's supply. Some over‑the‑counter products may be covered only with a written prescription, and replacement of lost or stolen medications is handled on a case‑by‑case basis.

The determination that a drug product or a particular use is experimental will be made by the Neighborhood Pharmacy & Therapeutics (P&T) Committee based on current medical literature. Drug products or uses identified by the P&T Committee as experimental are excluded from coverage as not medically necessary.

Prescriber and Pharmacy Requirements

Prior Authorization

Prior Authorization Required

Drugs listed as PA require prior authorization before dispensing. To obtain coverage, a prescriber or prescriber's representative must fax a completed Prior Authorization request to the Neighborhood Pharmacy Department or contact the department by phone. Each request is reviewed for individual patient need according to criteria approved by the Neighborhood P&T Committee.

Fax: 1-866-423-0945
Phone: 1-401-427-8200

Step Therapy

Step Therapy Requirement

Drugs labeled 'ST' require step therapy. Providers must document prior trials of specified formulary alternatives and may request an exception when required alternatives are inappropriate or contraindicated for the member.

Document prior trial(s) of required formulary agent(s)
If alternatives are inappropriate, request a Step Therapy exception

Documentation Required

Information Required for Exception or PA

When requesting a Prior Authorization or an exception, prescribers must provide clinical rationale and supporting documentation. Required information includes relevant diagnosis, medication history (prior trials, dates, and outcomes), contraindications or intolerance to formulary alternatives, and any supporting clinical records or test results.

Clinical rationale for the requested drug
Relevant diagnosis and clinical findings
Medication history: prior formulary or related agent trials, durations, and outcomes
Documentation of contraindications or adverse reactions to alternatives
Supporting records (labs, notes, test results) as applicable

Denial Risk

Denial Triggers and Process

Requests that do not meet exception or PA criteria may be denied. The Medical Director or Physician Reviewer will assess medical necessity, discuss recommendations with the prescriber, and provide written notification of any denial to the prescriber and member including the reason for the decision, applicable guidelines, and appeal rights.

If alternatives are recommended but deemed inappropriate, case referred to Medical Director/Physician Reviewer
Denials include explanation of applicable benefit or clinical guideline and appeal rights
Members may contact Customer Service to register an inquiry or complaint

Key Definitions

Formulary (definition)

DefinitionThe Formulary is the list of medications covered under the pharmacy component of the Neighborhood Managed Medicaid benefit for members, presented by drug class and searchable by brand/generic or index.

ScopeApplies only to outpatient drugs provided to members; does not apply to inpatient medications.

Listing detailsDrugs include requirement flags such as PA (Prior Authorization), ST (Step Therapy), QL (Quantity Limit), and OTC; limitations and requirements are shown in the Requirements/Limits column.

Coverage exclusionsDrug products not listed in the Formulary are not covered; experimental/off‑label uses, cosmetic products, and infertility treatments are excluded.

Preferred alternativesNeighborhood encourages use of generic drugs as first‑line alternatives when available.

Step Therapy (ST) (definition)

DefinitionStep Therapy (ST) is a requirement that a member try specified formulary products (formulary alternatives) prior to initiating the requested medication labeled ST.

Exception pathAn exception to step therapy may be requested and approved if the required alternatives are contraindicated or have failed for the member.

Prior Authorization (PA) (definition)

DefinitionPrior Authorization (PA) is a requirement that approval be obtained from the plan before certain drugs (listed as PA) will be covered at the pharmacy when the prescription is presented.

How to requestTo obtain coverage, prescribers may fax a completed Prior Authorization Request to Neighborhood Pharmacy Department or contact the Pharmacy Department by phone and provide required information.

Review processEach PA request is reviewed based on individual patient need and criteria approved by the Neighborhood P&T Committee; denials follow the Adverse Determination process.

Requirement	Details
Step therapy requirement
Members must try specified formulary products prior to initiating the requested ST medication unless an exception is approved. If required formulary products are not appropriate for the member or the member cannot take the formulary alternatives, the provider may request an exception to Step Therapy.