CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Drug Formulary — Outpatient Pharmacy Coverage Criteria

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

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDrug Formulary — Outpatient Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via fax to 1-866-423-0945 or call 1-800-459-6019 for review per P&T‑approved criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyP&T Committee meeting frequency

outpatientApplies to

1 monthDefault quantity limit

fax 1-866-423-0945PA fax

1-800-459-6019Member & provider contact

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.

Coverage Criteria

Formulary coverage and exceptions

Covered outpatient drugs unless otherwise restricted; Non-Formulary coverage allowed via exception when criteria met.

Formulary baseline: Drug is an outpatient prescription for a Neighborhood Managed Medicaid member and is listed on the Formulary

Formulary applies only to outpatient drugs

Exceptions for Non‑Formulary coverage (must demonstrate all)

ONE of the following must be met: (1) Use of Formulary products is contraindicated for the patient; (2) the patient has failed an appropriate trial of Formulary or related agents; OR (3) Formulary choices are not suited for the patient's clinical needs and the selected drug is required for patient safety
Prescriber should provide documentation of contraindication, prior trials/failures, or clinical rationale

Step Therapy

Step Therapy applies to drugs labeled "ST" on the Formulary.

Step Therapy requirement: Member must try required formulary alternatives prior to coverage of the requested ST drug unless an exception is granted

Provider may request exception when required alternatives are inappropriate or contraindicated

Coverage excludes drug products used for cosmetic purposes, drugs or uses determined to be experimental, and infertility treatments. The Formulary applies only to outpatient drugs and does not apply to inpatient medications. Certain B drug products listed on the Formulary website are not covered. 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 considered on a case‑by‑case basis.

Drugs or uses that the Neighborhood Pharmacy & Therapeutics Committee determines to be experimental are excluded from coverage as not medically necessary. The determination of whether a drug or a specific use is experimental is based on review of current medical literature by the P&T Committee; products identified as experimental are not covered under the Formulary.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required — submission channels and workflow. When a member presents a prescription for a non‑formulary or prior‑authorization (PA) required medication at a network pharmacy, the dispensing pharmacist will review the patient’s drug history and notify the prescriber that authorization is required. To obtain coverage, the prescriber or prescriber’s representative may: fax a completed Prior Authorization Request to the Neighborhood Pharmacy Department at 1-866-423-0945, or contact Neighborhood at 1-800-459-6019 and provide all necessary information requested. Each request is reviewed based on individual patient need and criteria approved by the Neighborhood P&T Committee.

Fax: 1-866-423-0945
Phone: 1-800-459-6019

Step Therapy

Step Therapy Requirement

Step Therapy (ST) applies to drugs labeled “ST.” Step Therapy requires trying specified formulary alternatives before the requested medication will be approved. If required formulary alternatives are not appropriate for the member (e.g., contraindication, intolerance, or clinical reason), the provider may request an exception to Step Therapy by submitting clinical rationale and supporting documentation for review.

ST drugs require trial of formulary alternatives before approval
Providers may request an exception when formulary alternatives are contraindicated or inappropriate

Documentation Required

Information to Include with Non‑Formulary Requests

Information to include with Non‑Formulary and Exception requests. Coverage of non‑formulary medications or requests for exceptions may be initiated by prescribers or members. When submitting a Non‑Formulary or formulary exception request, the prescriber must provide clinical information sufficient to allow a medical review. At minimum include: clinical diagnosis and relevant history, reason formulary agents are inappropriate or have failed, documentation of trials of related formulary agents (dates, doses, outcomes, adverse effects), any contraindications or safety concerns with formulary alternatives, and the proposed treatment plan (dose, duration, and expected benefit). Requests may be submitted by phone or fax to the Neighborhood Pharmacy Department and will be addressed by Neighborhood pharmacy and medical staff.

Diagnosis and clinical history
Documentation of trials of formulary or related agents (dates, doses, outcomes)
Reason formulary choices are contraindicated, ineffective, or unsuitable
Any safety or intolerance issues with formulary alternatives
Proposed medication, dose, duration, and expected benefit
Submit via fax to 1-866-423-0945 or phone 1-800-459-6019

Denial Risk

Denial and Notification

Denial and notification process. If a request does not meet criteria for a benefit exception, the request may be referred to the Neighborhood Medical Director or Physician Reviewer. After discussion with the prescriber, the Medical Director or Physician Reviewer will assess medical necessity and may approve or deny the request. If denied, the Medical Director or Physician Reviewer will discuss the reason for denial with the prescribing practitioner and provide written notification to both prescriber and member that documents the reasons for the decision, the applicable benefit or clinical guideline, and the member’s and prescriber’s appeal rights and procedures. Members may also register an inquiry or complaint with Member Services to receive standard response protocols and notification of appeal rights.

Denials are reviewed by the Medical Director or Physician Reviewer
Written notice to prescriber and member will explain reasons, applicable guideline/benefit, and appeal process
Prescriber may be contacted for discussion prior to final determination
Members may register inquiries/complaints with Member Services

Step	Requirement	Exception / Prior Authorization (PA) Pathway
1	Member must trial required formulary products listed as the designated alternatives (drugs labeled 'ST' on the Formulary) prior to coverage of the requested medication.	Provider may request an exception via the Prior Authorization process when required formulary alternatives are inappropriate or contraindicated for the member; submit PA by fax to 1-866-423-0945 or contact Neighborhood at 1-800-459-6019 for review.

Definitions

ST (Step Therapy) — definition

DefinitionMember must try specified formulary products prior to initiating the requested medication

Trigger on FormularyApplies to drugs labeled 'ST' on the Formulary

Exception processProviders may request an exception via Prior Authorization when required alternatives are inappropriate

PA (Prior Authorization) — definition

DefinitionDrug requires prior authorization from Neighborhood Pharmacy before coverage

How to requestPrior Authorization requests must be submitted by fax or phone per Neighborhood's PA process

ContactFax: 1-866-423-0945; Phone/Member & provider contact: 1-800-459-6019

QL (Quantity Limit) — definition

DefinitionIndicates a limit on the quantity of medication that can be dispensed to a member

Formulary notationDrugs listed with 'QL' on the Formulary have quantity limits specified

Publication of limitsSome Non‑Formulary medications are subject to Quantity Limitations and are specified on Neighborhood's website

OpenPayer

Drug Formulary — Outpatient Pharmacy Coverage Criteria

Coverage Criteria

Provider Actions and Prior Authorization

Step Therapy Details

Quantity Limits

Definitions

Background