CurrentNeighborhood Health Plan of Rhode IslandPolicy 000826

Benefit Exclusion

Lists medications, medication classes, and non-drug products that are excluded (not covered) from Neighborhood Health Plan of Rhode Island's pharmacy benefit across Medicaid, Medicare, FIDE, Commercial and CO-DSNP lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBenefit Exclusion

Policy CodePolicy 000826

Change TypeAdministrative/template update

Effective DateJuly 26, 2019

Next Review Date

Key ActionVerify that OTC products are listed on Neighborhood's formulary and ensure prescriptions are filled at a Neighborhood network retail pharmacy to be eligible for coverage.

SourceLink

POLICY UPDATE CHANGES

Yearly review and update to new policy template and new lines of business effective 1/1/26.

~30+distinct exclusion items or classes listed

Medicaid, Medicare, FIDE, Commercial, CO-DSNPlines of business referenced

2019-07-26; 2025-12-22policy effective/review dates

Policy: Pharmacy Benefit Exclusions

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.

ALL of the following

Biological products for allergy immunizations
Biological products for vaccinations
Blood fractions
Compound medications that are not made up of at least one legend drug
Drugs prescribed or dispensed outside of Health Plan dispensing guidelines
Drugs that have not been proven effective according to the FDA
Drugs used for cosmetic purposes
Drugs or products whose manufacturer does not participate in the Medicaid Drug Rebate Program (MDRP) (i.e., the manufacturer does not have a signed National Drug Rebate Agreement on file with the Secretary of the Department of Health and Human Services)
Experimental drugs (including those placed on notice of opportunity hearing status by the Federal Drug Efficacy Study Implementation [DESI])
Medications an enrollee may take or was given while residing in a hospital, rest home, sanitarium, nursing home, home care program, or other institution that provides prescription drugs as part of its services or which operates its own facility for dispensing prescription drugs
Non-medical substances (regardless of the reason prescribed, the intended use, or medical necessity)
Off-label use of drugs, unless mandated by laws pertaining to the treatment of cancer
Support garments and other durable medical equipment (except for diabetic testing supplies)
Therapeutic devices and appliances, including hypodermic needles and syringes (except when used to administer insulin or for self-administration of FDA-approved injectable drugs)
Medications prescribed for the treatment of sexual or erectile dysfunction (ED)
Medical marijuana
Medications for infertility treatment

(All items listed above are excluded from Medicaid pharmacy coverage)

Benefit Exclusions — Commercial

The following items are considered Benefit Exclusions and are therefore not covered by Neighborhood's Commercial Benefit:

ALL of the following

Any drug product used for cosmetic purposes
Experimental drug products, off-label use of drug products, or any drug product used in an experimental manner (unless mandated by laws pertaining to the treatment of cancer)
Medications prescribed for sexual and/or erectile dysfunction (ED)
Medical marijuana
Compounded products that are not made up of at least one legend drug
Prescription and OTC homeopathic drugs
Non-drug products such as therapeutic or other prosthetic devices, appliances, supports, or other non-medical products (except diabetic testing supplies)
Drugs that cannot be lawfully marketed without the approval of the FDA and such approval has not been granted at the time of their use or proposed use or such approval has been withdrawn
Prescriptions filled at pharmacies other than Neighborhood network retail pharmacies, except for emergency care
Prescription drugs once the same active ingredient or a modified version of an active ingredient is available over-the-counter
Prescription drugs when packaged with non-prescription products
OTC drugs/products are not covered unless they are listed on our formulary on our website at www.nhpri.org.

(All items listed above are excluded from Commercial pharmacy coverage)

Benefit Exclusions — Medicare (including Medicare portion of FIDE)

The following items are considered Benefit Exclusions and are therefore not covered by Neighborhood's Medicare Benefit:

ALL of the following

Medications that Medicare Part A or Medicare Part B already cover
Medications used for sexual or erectile dysfunction
Medications used for the treatment of infertility
Medications used for cosmetic purposes or to promote hair growth
Medications made by a manufacturer who requires associated tests or monitoring services be purchased only from them as a condition of sale
Medications being used for indications that are not FDA-approved or compendia-supported (e.g., off-label use)
Medications purchased outside the United States and its territories
Non-prescription drugs, drugs used for the symptomatic relief of cough or cold symptoms, prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations), drugs used to treat anorexia, weight loss, or weight gain
Note: Some drugs excluded here may still be coverable under the Medicaid portion of the FIDE benefit but are not payable by the Medicare FIDE or CODE benefits
Note: Some weight loss drugs may be covered under the Medicare portion of the benefit according to the GENEROUS pilot CMS Innovation model in mid-2026

(All items listed above are excluded from Medicare pharmacy coverage)

Regulatory and Reference Documents

Regulatory / Reference Documents Citedmixed

Medicare Prescription Drug Benefit Manual, Chapter 6 - Part D Drugs and Formulary Requirements, Section 20	Regulatory reference cited in policy
EOHHS Medicaid Managed Care Manual (Medicaid Managed Care Pharmacy Benefit Plan Protocols), Effective 7/1/2023	State Medicaid protocol cited
Contract between State of Rhode Island EOHHS and Neighborhood Health Plan of Rhode Island for Medicaid Managed Care Services, Effective 7/1/2025	Contract cited
Agreement between The Rhode Island Health Benefits Exchange and Neighborhood Health Plan of Rhode Island, Dated 10/8/2015	Agreement cited

Provider Impact and Requirements

Documentation Required

Formulary reference for OTC coverage

OTC products are not covered unless they are listed on Neighborhood's formulary on the plan website; when prescribing an OTC product for coverage, confirm it is listed on the formulary and be prepared to provide documentation of formulary listing if required for payment.

Prior Authorization

Network pharmacy requirement (Commercial)

For Commercial members, prescriptions must be filled at Neighborhood network retail pharmacies; prescriptions filled at pharmacies other than Neighborhood network retail pharmacies are not covered except for emergency care.

Denial Risk

Off-label and experimental use

Off-label uses and experimental uses are excluded and may be denied if submitted without a mandated legal exception; exceptions apply only when use is mandated by laws pertaining to the treatment of cancer.

Documentation Required

Manufacturer-required ancillary services

Medicare excludes medications made by manufacturers who require that associated tests or monitoring services be purchased only from them as a condition of sale; verify any manufacturer purchase or monitoring requirements prior to prescribing for Medicare members.

Clinical and Administrative Context

This policy enumerates products, medication classes, and related non-drug items that are excluded from coverage under Neighborhood Health Plan of Rhode Island’s pharmacy benefits across lines of business, including Medicaid, Medicare, FIDE, Commercial, and CO-DSNP. It identifies items the plan will not cover (Benefit Exclusions) and cross-references member-facing documents where these exclusions are published, such as the Medicaid Member Handbook, Commercial Certificate of Coverage, FIDE Member Handbook, and CODE Evidence of Coverage.

Exclusions are applied in the context of applicable federal and state regulatory constraints. Relevant regulatory and contractual references include the Medicare Prescription Drug Benefit Manual, Chapter 6 - Part D as well as state documents such as the EOHHS Medicaid Managed Care Pharmacy Benefit Plan Protocols and the contract between the State of Rhode Island EOHHS and Neighborhood Health Plan of Rhode Island. The policy also notes program-specific rules (for example, Medicare Part D/Part A/Part B coverage interactions) that affect what is excluded from the pharmacy benefit.

The document was last reviewed and administratively updated on December 22, 2025, reflecting a yearly review and template/lines-of-business update effective 1/1/26; no material clinical coverage additions or removals are called out in the body of the policy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBenefit Exclusion

Policy CodePolicy 000826

Change TypeAdministrative/template update

Effective DateJuly 26, 2019

Next Review Date

Key ActionVerify that OTC products are listed on Neighborhood's formulary and ensure prescriptions are filled at a Neighborhood network retail pharmacy to be eligible for coverage.

SourceLink

On This Page

OpenPayer

Benefit Exclusion

Policy: Pharmacy Benefit Exclusions

Regulatory and Reference Documents

Provider Impact and Requirements

Clinical and Administrative Context

Policy Changes

Benefit Exclusion

Policy: Pharmacy Benefit Exclusions

Regulatory and Reference Documents

Provider Impact and Requirements

Clinical and Administrative Context

Policy Changes

Defined Terms

Other Policies to Review