CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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

Defines expectations for use of Neighborhood Health Plan of Rhode Island formularies and prior authorization procedures for members residing in assisted living and long-term care facilities; affects providers and dispensing pharmacies serving these members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization when a member requires a drug not included in their formulary or when a drug has a restriction.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2document sections / chunks

formulary-basedcoverage approach

prior auth requiredauthorization trigger

Coverage Criteria

Drugs that are not on a member's formulary — including non-formulary over-the-counter (OTC) products — are not automatically covered. Coverage for these products requires advance approval through Neighborhood's prior authorization process.

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Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-formulary drugs, non-formulary OTC drugs, and medications that have utilization management restrictions. Dispensing pharmacies serving members in assisted living and long-term care facilities may require a prior authorization be submitted before placing an override and dispensing the medication.

Applies to drugs not included on member's formulary
Includes non-formulary OTC drugs and drugs with utilization management restrictions
Pharmacies may require prior authorization before override/dispense

Note

Submit Prior Authorization

Providers must work with Neighborhood to obtain approval by submitting a prior authorization when a member requires a drug not included in their respective formulary. Refer to the most up-to-date Neighborhood formularies (by line of business) on the Neighborhood website before prescribing.

Submit prior authorization to Neighborhood for non-formulary and restricted medications
Check member's formulary on Neighborhood website prior to prescribing

Denial Risk

Prior Authorization May Be Required — Risk of Disruption

Failure to submit a required prior authorization for a non-formulary, OTC, or restricted drug may prevent approval and disrupt the member's access to the medication. To avoid delays, confirm formulary status and submit the prior authorization promptly when a non-formulary or restricted medication is medically necessary.

Lack of prior authorization can result in denial or dispensing delays
Confirm formulary inclusion before dispensing or requesting override

Applicable Site of Care

Documentation Required

Apply policy to assisted living and long‑term care settings

This policy applies to members residing in assisted living and long‑term care facilities; dispensing pharmacies serving these facilities should follow formulary and prior authorization requirements and may request prior authorization before overriding and dispensing.

Definitions

Formulary

DefinitionFormulary: the list of covered drugs maintained by Neighborhood, organized by line of business on the plan website.

LocationFormularies are listed by line of business on Neighborhood's website; refer to the most up-to-date versions online.

Coverage implicationDrugs not included on a member's formulary, including non-formulary OTC drugs, are not automatically covered and require prior authorization.

Provider responsibilityProviders must work with Neighborhood to obtain approval by submitting a prior authorization when a required drug is not on the member's formulary or has a restriction.

Pharmacy practiceDispensing pharmacies serving assisted living and long-term care facilities may request a prior authorization for drugs with utilization management restrictions (including non-formulary and OTC drugs) before placing an override and dispensing.

Background

Neighborhood expects provider partners to follow the plan formularies when developing medication plans for members in assisted living and long-term care facilities. When a required medication is not included on the member's formulary, is a non-formulary OTC, or is subject to a utilization management restriction, providers must work with Neighborhood to obtain approval by submitting a prior authorization. Dispensing pharmacies servicing these settings may request that a prior authorization be submitted before placing an override and dispensing the medication.