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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsNeighborhood Health Plan RI Commercial Formulary C…
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    CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

    Neighborhood Health Plan Formulary (Commercial) — Outpatient Drug Formulary Coverage Criteria

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    Defines the outpatient drug formulary, coverage rules, prior authorization, step therapy, exceptions, and processes for prescribers, pharmacists, and members under Neighborhood Health Plan of Rhode Island's Commercial pharmacy benefit.

    Policy Summary
    PayerNeighborhood Health Plan of Rhode Island
    PolicyNeighborhood Health Plan Formulary (Commercial) — Outpatient Drug Formulary Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2026
    Next Review DateN/A
    Key ActionPrescribers must fax or call to submit Prior Authorization requests for drugs listed as 'PA' and provide clinical information to support exceptions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    quarterlyP&T committee meeting frequency
    outpatient onlyApplies to

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    PA, QL, STFormulary controls
    fax & phonePA submission

    Formulary Coverage and Exclusions

    Formulary coverage and exception criteria

    Coverage and exceptions for outpatient formulary drugs are governed by the following conditions:

    General Formulary Coverage: The Formulary applies only to outpatient drugs provided to members; some OTC products may be covered only with a written prescription; drug products used for cosmetic purposes, experimental or off-label uses, and drugs failing industry-standard patient safety screens are not covered.

    See Coverage Limitations

    Exceptions eligible for Non-Formulary coverage

    • Formulary products are contraindicated for the patient.

      Prescriber documents contraindication

    • The patient has failed an appropriate trial of formulary or related agents.

      Prescriber documents prior therapy and failure

    • Formulary choices are not suited for the patient's clinical need or their use would jeopardize patient safety (e.g., would provoke an underlying condition detrimental to care).

      Prescriber documents rationale and safety concern

    Operational exception process: When a non-formulary medication is needed, the dispensing pharmacist will evaluate drug history and contact the prescriber; the prescriber must call or fax Neighborhood Pharmacy/medical staff to request coverage and provide supporting clinical information for review by Neighborhood pharmacy and medical staff (P&T criteria).

    See Exception Process for required steps

    The Formulary applies only to outpatient drugs provided to members. Excluded from coverage are: drug products used for cosmetic purposes, drug products determined to be experimental (including those used in an experimental or off‑label manner), and drug products that fail industry‑standard patient safety screens unless additional clinical information is provided by the prescriber.

    Drug products used for cosmetic purposes and products determined to be experimental or used in an experimental/off‑label way are considered not covered / not medically necessary under the Formulary. The determination of whether a product or its use is experimental will be made by the PBM’s Pharmacy & Therapeutics Committee using current medical literature.

    Prescriber and Pharmacy Requirements

    Prior Authorization

    Prior Authorization Required

    Prior Authorization is required for drugs listed with the PA designation in the Formulary. When a member presents a prescription for a PA drug at a network pharmacy, coverage must be approved before the claim can be processed. Prior authorization requests are reviewed on the individual patient's clinical need and in accordance with criteria approved by the Pharmacy & Therapeutics (P&T) Committee.

    • PA-coded drugs in the Formulary require prior authorization before coverage.
    • Submit completed Prior Authorization requests by fax or phone using the contact details below.
    • Each request is reviewed against P&T-approved criteria and the member's clinical record.
    Step Therapy

    Step Therapy Requirements

    Step Therapy (ST) requirements apply to drugs listed with the ST designation. Step Therapy requires that specified formulary alternatives be tried and documented as ineffective or intolerable before the requested (ST) medication will be covered. If the required formulary alternatives are inappropriate for the member (e.g., contraindication, intolerance, or other clinical reason), the prescriber may request a Step Therapy exception.

    Key Terms

    Therapeutic interchange (inv-09)
    DefinitionTherapeutic interchange: replacing a prescribed medication with a chemically different medication (with the prescribing physician's approval) expected to produce similar clinical effectiveness and sound medical outcomes based on available scientific evidence.
    Operational noteTherapeutic interchange is performed on an individual basis; Neighborhood Pharmacy staff will contact the prescriber’s office when interchange is considered appropriate.
    Prescriber involvementPrescriber approval is required before implementing a therapeutic interchange.

    Step Therapy Criteria

    StepRequirementException allowed
    1
    Must try specified formulary products (listed as formulary alternatives) prior to initiating the requested medication
    Provider may request an exception if required formulary alternatives are inappropriate or the member cannot take them

    Formulary Quantity Limits

    Formulary-listed QL drugs (inv-11)
    ScopeQuantity limits apply to drugs labeled 'QL' in the Formulary.
    Limit frequencyLimits are defined per the Formulary's Requirements/Limits column (e.g., monthly supply limits as specified).
    How to find limitsConsult the Formulary PDF or the online searchable formulary (by drug class, index, or Brand & Generic Name Search) for specific QL values.
    Most actionableIf a prescription is marked 'QL' in the Formulary, follow the specific quantity limit shown in the Formulary prior to dispensing or requesting authorization.

    Formulary Governance

    The Formulary is maintained and evaluated by the Pharmacy & Therapeutics (P&T) Committee. The Committee reviews drugs for safety, efficacy, effectiveness, duplication, cost, and any restrictions; determinations about whether a product or a use is experimental are made by the P&T Committee based on current medical literature.

    Policy Summary
    PayerNeighborhood Health Plan of Rhode Island
    PolicyNeighborhood Health Plan Formulary (Commercial) — Outpatient Drug Formulary Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2026
    Next Review DateN/A
    Key ActionPrescribers must fax or call to submit Prior Authorization requests for drugs listed as 'PA' and provide clinical information to support exceptions.
    SourceLink
    On This Page
    Formulary Coverage and ExclusionsPrescriber and Pharmacy RequirementsKey TermsStep Therapy CriteriaFormulary Quantity LimitsFormulary Governance
    • ST-coded drugs require documented trials of the specified formulary alternative(s) prior to coverage of the requested agent.
    • If a formulary alternative is contraindicated or has caused intolerance, document the clinical reason when requesting an exception.
    • The exception process (see documentation callout) should be used to request coverage without meeting step requirements.
    Documentation Required

    Required Documentation for Prior Authorization / Exception Requests

    To request prior authorization or an exception (including Step Therapy exceptions or Non‑Formulary coverage), the prescriber must provide supporting clinical documentation demonstrating medical necessity. Required documentation includes relevant diagnoses, prior medication trials (drug name, dose, dates, and reason for failure or intolerance), clinical rationale for the requested agent, and any relevant laboratory or clinical test results.

    • Documentation should include: diagnosis, prior drug trials with dates/doses and reason for discontinuation, and supporting clinical notes or test results.
    • Fax completed Prior Authorization form and supporting documentation to Neighborhood Pharmacy Department: 1-866-423-0945.
    • Or contact Neighborhood Pharmacy Department by phone at 1-401-427-8200 to initiate the request and provide required clinical information.
    Denial Risk

    Denial Process and Notifications

    If a request does not meet criteria for coverage, Neighborhood will issue an adverse determination. The prescriber and member will be notified in writing of the decision, the clinical rationale, applicable benefit or guideline references, and appeal rights. Reviewers (Medical Director or Physician Reviewer) will discuss denials with the prescribing practitioner when appropriate.

    • Denials will include reason(s), supporting guidelines or protocols, and instructions for filing an appeal.
    • Prescribers may be referred to the Neighborhood Medical Director or Physician Reviewer for further discussion of clinical rationale.
    • Members may contact Customer Service to file an inquiry or complaint; standard response and appeal notification protocols apply.