CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medications Covered under the Pharmacy Benefit Only

Identifies specific pharmaceutical products that will be covered exclusively through Neighborhood Health Plan of Rhode Island's pharmacy benefit (affecting commercial members and providers) and the prior authorization requirement when criteria are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedications Covered under the Pharmacy Benefit Only

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateJun 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for Hemlibra (emicizumab) when clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1medication listed as pharmacy-benefit-only

60-dayadvance notification period

180-daymedical lookback period

Commercialscope/plan affected

Coverage Criteria

Pharmacy Benefit Exclusive Coverage

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedications Covered under the Pharmacy Benefit Only

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateJun 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for Hemlibra (emicizumab) when clinical criteria are met.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Hemlibra (emicizumab) is covered exclusively under the pharmacy benefit and requires prior authorization when clinical criteria are met. Requests for coverage under the medical benefit may be denied if the drug is designated pharmacy‑benefit‑only.

Affected product: Hemlibra (emicizumab)
Prior authorization required under pharmacy benefit
Medical benefit requests may be denied for pharmacy‑benefit‑only drugs
Members/providers receive 60‑day advance notice if medication was obtained under medical benefit in prior 180 days

Note

Prior Authorization and Member/Provider Notification

Prior authorization and notification: Medications listed as pharmacy‑benefit‑only require prior authorization through the pharmacy benefit. If a member has received the medication under the medical benefit within the previous 180 days, Neighborhood Health Plan of Rhode Island will provide a 60‑day advance notification to the member and provider regarding the change to pharmacy‑only coverage.

Prior authorization required for pharmacy‑benefit‑only medications
60‑day advance notification when the member obtained medication under medical benefit in prior 180 days

Billing Rule

Pharmacy Benefit Exclusivity

Coverage is limited to the pharmacy benefit. Do not bill the medical benefit for Hemlibra (emicizumab) when it is designated pharmacy‑benefit‑only; such medical benefit requests may be denied.

Pharmacy benefit exclusivity: Hemlibra (emicizumab)

Definitions

Pharmacy benefit only — definition and implications

DefinitionPharmacy-benefit-only: medications designated to be covered and dispensed through the plan's pharmacy benefit rather than the medical (provider‑administered) benefit.

Coverage implicationMedications listed as pharmacy-benefit-only are covered under the pharmacy benefit and require prior authorization when clinical criteria are met.

Notification requirementMembers and providers will receive a 60-day advance notification if the member obtained the medication under the medical benefit within the prior 180 days.

Medical benefit requestsRequests to obtain the product through the medical benefit may be denied if the product is designated pharmacy‑benefit‑only.

ScopeThis designation applies to the listed product(s) for applicable commercial members as specified by the policy.