CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Preferred and Non-Preferred Drug List Program Coverage Criteria

Defines the payer's Preferred Drug List (PDL) and Non-Preferred Drug List processes, authorization handling, and procedures for network providers and pharmacy staff; applies to medications managed by the health plan and Evolent for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPreferred and Non-Preferred Drug List Program Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request for non-preferred medications following normal pre-service procedures and provide clinical references for non-label use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AnnualPDL review frequency by Pharmacy

24 hrsInitial review of payer change notification

72 hrsAnalysis period after initial review

4-10 daysSystem update window (CarePro)

Risk Comm/MedicaidLines receiving RAD for non-preferred

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 and Authorization Criteria

inv-01: Continuation Therapy Conditions

Continuation requests for a non-preferred medication may be approved when ALL of the following are met:

Continuation criteria: The requested medication was used within the last year.

Continuation allowance per policy: applies to previously used non-preferred medications.

Continuation criteria: The member has not experienced disease progression and/or has not had intolerance to the requested medication.

Clinical stability or tolerability required for continuation approval.

Continuation criteria: No additional medication(s) are being added to the continuation request.

Applies only when the request is limited to continuation of the existing agent(s).

inv-02: Permitted Use of Non-Preferred Alternatives

Alternative use allowed when ANY of the following are present:

Allowed alternative scenarios: Documented drug shortage.

See FDA drug shortage website referenced in policy for current shortages.

Allowed alternative scenarios: Disease progression making the preferred agent inappropriate.

Clinical judgment required; alternative must be medically appropriate and indication supported by compendia or literature.

Allowed alternative scenarios: Contraindication to the preferred drug/regimen.

Documented contraindication required; alternative must be supported by standard references.

Allowed alternative scenarios: Confirmed intolerance to a preferred drug/regimen.

Evolent is responsible for processing all medication requests from network ordering providers. Medications not authorized by Evolent may be deemed not approvable and therefore not reimbursable. Providers must submit authorization requests through the normal pre-service process and include required clinical documentation; failure to obtain Evolent authorization may result in denial of reimbursement.

inv-11: Initial Therapy Guidance

Initial requests handling

Initial request guidance: Refer to the Health Plan Policy and/or Evolent Preferred Drug Policy and applicable hierarchy for medical decision making.

Initial requests for non-preferred drugs are not auto-approved and require prior authorization per policy.

Initial request guidance: Preferred alternatives should be recommended to providers when applicable.

Follow the applicable Health Plan or Evolent Preferred Drug Policy for initial decision making.

Provider Responsibilities and Authorization Process

Prior Authorization

Prior Authorization Required for Non-Preferred Medications

Any authorizations containing a non-preferred medication will not be auto-approved. Providers must submit a pre-service authorization request following the Standard Pre-Service Request for Authorization (UM_1009) procedures for medical necessity review.

Follow the Health Plan Policy and/or Evolent Preferred Drug Policy for initial requests.
Continuation requests for a not-approvable medication are exempt from this policy only if: the medication was used within the last year; the member has not had disease progression or intolerance to the requested medication; and no additional medications are being added to the continuation request.
When documented drug shortages, disease progression, contraindication, or confirmed intolerance to a preferred drug exist, an alternative product may be used if supported by a standard reference compendium or accepted peer-reviewed literature.

Step Therapy

Steering to Preferred Alternatives

Evolent will attempt to switch non-preferred agents to preferred alternatives except where a hard steer is required. For Risk Commercial/Exchange and Medicaid cases, Evolent will issue a Recommended Adverse Determination (RAD, “hard steer”) for requests involving a non-preferred Evolent agent/regimen. For all other lines of business, Evolent will attempt a “soft steer” to a preferred alternative.

Key Definitions

inv-09: Preferred Drug List — definition and criteria for preferred drugs

DefinitionMedications identified by Evolent or the payer as having the highest level of evidence supporting effectiveness, the least toxicity, and, when factors are equal, the lowest cost.

Primary purposeDesignate preferred therapeutic options to guide prescribing toward agents with superior evidence, safety, and cost-effectiveness.

Use in utilization managementPreferred drugs are recommended as first-line options and are promoted as alternatives when non-preferred medications are requested.

Review frequencyAnnual review by Pharmacy (PDL review frequency).

Action for providersProviders should consider preferred alternatives per Health Plan and Evolent Preferred Drug Policy when submitting initial requests.

Program Background

Preferred drugs are medications identified by Evolent or the payer as having the highest level of evidence supporting effectiveness, the least toxicity, and, when factors are equal, the lowest cost. These agents are promoted to ensure clinically appropriate and cost-effective care and are the first-line options for initial therapy decisions.

Selection of preferred agents is guided by clinical evidence and safety profiles and is reflected on the plan's Preferred Drug List. Non-preferred drugs are maintained to prevent inappropriate use and to encourage use of preferred alternatives; they are not auto-approved and require prior authorization when requested.

When a preferred agent is not appropriate (for example, documented drug shortage, disease progression, contraindication, or confirmed intolerance), an alternative non-preferred product may be used if medically appropriate and the indication is supported by a standard reference compendium or accepted peer-reviewed literature.

Continuation Therapy Criteria

inv-12: Continuation Therapy Exemption

Continuation requests for a non-preferred medication shall be exempt from non-approval when the following ALL apply:

Continuation exemption: Requested medication was used within the last year.

Exemption applies to continuation requests only; aligns with Evolent continuation allowance.

Continuation exemption: The member has not experienced disease progression and/or no intolerance to the requested medication.

Clinical stability or tolerability required for exemption from non-approval.

Continuation exemption: No additional medication(s) are being added to the continuation request.

Exemption invalid if new agents are added to the regimen.

Step Therapy and Steering

Line of Business	Action for Authorization Requests	Coverage Label
Risk Commercial/Exchange
Evolent will issue a Recommended Adverse Determination (RAD; 'hard steer') for authorization requests containing a non-preferred Evolent agent/regimen.
Recommended Adverse Determination (hard steer)
Medicaid
Evolent will issue a Recommended Adverse Determination (RAD; 'hard steer') for authorization requests containing a non-preferred Evolent agent/regimen.
Recommended Adverse Determination (hard steer)
All other lines of business
Evolent will attempt to switch ('soft steer') the non-preferred agent/regimen to an Evolent preferred alternative (soft steer).
neutral