CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prescription Coverage in Assisted Living and Long-Term Care Facilities - Drug

Governs authorization and dispensing procedures for drugs (including non-formulary and OTC medications) for Neighborhood Health Plan of Rhode Island members residing in assisted living and long-term care facilities; applies to provider partners and dispensing pharmacies serving those members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrescription Coverage in Assisted Living and Long-Term Care Facilities - Drug

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a drug prior authorization when a member requires a medication not on their formulary or with utilization management restrictions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1document chunk sources

assisted & long-term caresettings covered

non-formulary & OTCdrug types

Coverage Criteria

The source document does not state specific stepwise coverage criteria or detailed medical necessity rules. It primarily sets administrative expectations: use Neighborhood formularies and obtain approval when a member residing in an assisted living or long‑term care facility requires a drug that is not on the member’s formulary, is a non‑formulary over‑the‑counter (OTC) product, or has a utilization management restriction. In those circumstances providers should submit a prior authorization to request approval for dispensing.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required when a Neighborhood member requires a drug that is not included on their formulary, for non-formulary over-the-counter (OTC) drugs, or for medications subject to utilization management restrictions. Providers must obtain approval before prescribing or dispensing these drugs.

Applies to non-formulary drugs, non-formulary OTC drugs, and medications with utilization management restrictions

Prior Authorization

Authorization Needed for Non-Formulary or Managed Drugs

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrescription Coverage in Assisted Living and Long-Term Care Facilities - Drug

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a drug prior authorization when a member requires a medication not on their formulary or with utilization management restrictions.

SourceLink

On This Page

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When a drug is non-formulary or subject to utilization management, providers and dispensing pharmacies should not assume automatic coverage. An authorization must be submitted and approved to avoid coverage denial or the need for an override at the point of dispensing.

Includes medications with step therapy, quantity limits, or other utilization controls

Documentation Required

How to Submit Authorization

Providers must submit a drug prior authorization request to Neighborhood to obtain approval when a member requires a drug that is not covered by the member's formulary or is subject to utilization management. Submit the authorization with clinical rationale and relevant documentation to support medical necessity.

Include member identifiers, drug name, strength, dosing, and clinical justification
Provide prior medication history and reason formulary alternatives are unsuitable

Denial Risk

Risk of Denial if Authorization Not Submitted

If an authorization is not submitted and approved for non-formulary or managed drugs, the claim may be denied and the medication will not be covered. This may result in delayed therapy or out-of-pocket costs for the member.

Denial or need for pharmacy override may occur at dispensing
Members may be responsible for full cost if authorization is not obtained

Applicable Site of Care

Note

Applies to assisted living and long‑term care residents

This policy and its authorization requirements apply to Neighborhood members residing in assisted living and long‑term care facilities.

Key Definitions

Non-formulary

DefinitionNon-formulary: a medication not listed on the member's drug formulary.

ImplicationDrugs not on the member's formulary require prior authorization before dispensing for members in assisted living and long-term care facilities.

Who it applies toApplies to Neighborhood Health Plan of Rhode Island members residing in assisted living and long-term care facilities.

Pharmacy actionDispensing pharmacies may request an authorization or place an override when a medication is non-formulary and has a utilization management restriction.

OTC

DefinitionOTC (over-the-counter): medications available without a prescription; may still be non-formulary for a member.

Authorization requirementOver-the-counter medications that are non-formulary or have utilization management restrictions require prior authorization before dispensing.

Pharmacy practiceDispensing pharmacies serving assisted living and long-term care members may request an authorization or place an override to dispense OTC drugs that are non-formulary or restricted.

Provider responsibilityProviders should work with Neighborhood to submit a drug prior authorization when an OTC medication is not on the member's formulary or is restricted.

Background and Scope

Neighborhood Health Plan of Rhode Island emphasizes ensuring access to safe and cost‑effective medication options for members residing in assisted living and long‑term care facilities and expects provider partners to use Neighborhood drug formularies when designing treatment plans. When a required medication is not on the member’s formulary, is a non‑formulary OTC, or carries a utilization management restriction, providers and dispensing pharmacies are asked to work with Neighborhood by submitting a prior authorization so the medication can be approved and dispensed.