CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-Preferred and Preferred Drug List

Defines the payer's program and procedures for managing preferred and non-preferred medications, including prior authorization handling, preferred alternative guidance, and responsibilities for New Century Health and the health plan; affects network ordering providers, pharmacy/UM staff, and member benefit administration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Preferred and Preferred Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective Date03/08/23

Next Review DateN/A

Key ActionObtain prior authorization for non-preferred medications; continuation exemptions apply only when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualPDL review cadence by Pharmacy

24hinitial NCH review after payer change notification

72hanalysis period after initial review

4-10dsystem update window

03/08/23document approval date

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Coverage and Clinical Criteria

Preferred Medication Guidance and Continuation

Coverage and approval behaviors for preferred vs non-preferred medications

Continuation request exemption: Continuation requests for a non-preferred (not-approvable) medication are exempt from this NCH policy provided all of the following are met: the requested medication was used within the last year; the member has not experienced disease progression and/or intolerance to the requested medication; and additional medication(s) are not being added to the continuation request.

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When alternative allowed: When there is a documented drug shortage, disease progression, contraindication, or confirmed intolerance to a preferred drug/regimen, the available alternative product may be used if medically appropriate and the indication is listed in a standard reference compendium or accepted peer review literature.

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Authorization behavior for non-preferred agents: Authorizations containing a non-preferred medication will not be auto-approved. For Risk Commercial/Exchange and Medicaid cases NCH will issue a Recommended Adverse Determination (RAD, a hard steer); for other lines NCH will attempt a soft steer to a preferred alternative. For medical necessity determinations follow the Standard PreService Request for Authorization procedures.

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Treatment requests for medications that fall outside the approved FDA manufacturer labeling or CMS‑approved compendia must follow approved clinical criteria. New Century Health (NCH) is responsible for processing all medication requests from network ordering providers; when requests fall outside these sources, providers must supply supporting references and documentation to allow clinical review — absence of such references may delay processing.

Provider Responsibilities and Authorization Workflow

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-preferred drugs. Initial and continuation requests are processed by New Century Health (NCH). Authorization is required for non-preferred medications and such requests will not be auto-approved; NCH will process and determine authorization status per clinical policy.

All medication requests from network ordering providers are processed by NCH.
Medications not authorized by NCH may be deemed not approvable and not reimbursable.

Step Therapy

Preferred Alternative / Steering

NCH uses preferred alternative guidance to steer use toward preferred agents. ICs, FLRs, and CRs may outreach to providers to recommend preferred alternatives. For Risk Commercial/Exchange and Medicaid cases, NCH will issue a Recommended Adverse Determination (hard steer) for requests containing a non-preferred agent/regimen. For other authorization requests, NCH will attempt a soft steer to convert the request to an NCH preferred alternative.

ICs, FLRs, and/or CRs will outreach to provider offices regarding preferred alternative medications.

Key Definitions

Preferred Drug List — Definition entry

DefinitionMedications New Century Health or the payer identifies as having the highest level of evidence supporting effectiveness, the least toxicity, and, when factors are equal, the lowest cost.

PurposeServes as the roster of preferred agents used to guide medical decision-making and utilization management toward evidence-based, lower-toxicity, and cost-considered therapies.

Use in policyPreferred items are referenced by NCH and the Health Plan when evaluating initial requests and for steering strategies to preferred alternatives.

Non-Preferred Drug List — Definition entry

DefinitionMedications New Century Health or the payer identifies as non-preferred and therefore not auto-approved.

Function

Program Background

Items placed on the payer's Preferred Drug List are identified based on their evidence of effectiveness, safety profile, and, when other factors are equal, cost. The Preferred Drug List is used to steer prescribing toward agents with the best balance of efficacy and toxicity and to encourage use of preferred alternatives through prior authorization and utilization management processes. Non‑preferred medications are not auto‑approved and require NCH authorization; if not authorized, they may be deemed not approvable and therefore not reimbursable.

Initial Request Criteria

Initial Requests

Initial request handling

Initial request guidance: Refer to the Health Plan Policy (if applicable) and/or the NCH Preferred Drug Policy (if applicable) for guidance. In addition, check the applicable hierarchy for medical decision making for the Health Plan.

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Continuation (Exemption) Criteria

Continuation Exemption

Criteria for continuation (exemption) of non-preferred medications

Continuation criteria: Requested medication was used within the last year AND the member has not experienced disease progression or intolerance to the requested medication AND no additional medication(s) are being added to the continuation request.

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Step Therapy and Steering Procedures

Step	Requirement	Notes / Roles
1	NCH will attempt to steer non-preferred medication requests to a preferred alternative.	For authorization requests other than Risk Commercial/Exchange and Medicaid, NCH will attempt a soft steer to a preferred alternative.
2	Intake Coordinators (ICs), First-Level Reviewers (FLRs), and Clinical Reviewers (CRs) shall outreach to providers' offices regarding the preferred alternative medication.	Outreach is directed to the provider office to encourage conversion to the preferred agent; training is provided to ICs/FLRs/CRs prior to new strategies.
3	FLRs may approve authorizations when appropriate.	Authorizations containing a non-preferred medication will not be auto-approved; FLRs have authority to approve when criteria met.
4	For Risk Commercial/Exchange and Medicaid cases, NCH will issue a Recommended Adverse Determination (hard steer) for requests with a non-preferred agent/regimen.	Hard steer results in a Recommended Adverse Determination per clinical policy for these lines of business.