CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prescription Drug Coverage In Assisted Living And Long Term Care Facilities

Guidance for providers and dispensing pharmacies serving Neighborhood Health Plan of Rhode Island members in assisted living and long-term care facilities about using plan formularies and submitting prior authorizations for non-formulary, OTC, or restricted medications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrescription Drug Coverage In Assisted Living And Long Term Care Facilities

Policy CodePolicy N/A

Change Typeclarified

Effective DateOct 1, 2025

Next Review Date

Key ActionIf a member requires a drug not on their formulary, including non-formulary OTC drugs or medications with restrictions, providers must submit a prior authorization to obtain approval before prescribing or dispensing.

SourceLink

POLICY UPDATE CHANGES

Reminds providers to use Neighborhood formularies and to submit prior authorization requests for non-formulary, OTC, or restricted medications for members in assisted living and long-term care facilities.

1Document Purpose Statements

Summary & Scope

Neighborhood advises provider partners to follow plan formularies when treating members in assisted living and long-term care facilities and notes that prior authorization processes apply for non-formulary, over-the-counter, or restricted medications to ensure safe and cost-effective treatment.

Change Summary

Clarified reminder: dispensing pharmacies may require prior authorization before placing an override and dispensing restricted drugs. Providers should use Neighborhood formularies and submit prior authorization requests for non-formulary, OTC, or restricted medications for members in assisted living and long-term care facilities.

Note: coverage_stance = informational; has_material_change = false.

Change detail	Type	Material?
Dispensing pharmacies may require PA before override/dispense for restricted drugs.	clarified	false

Required Provider & Pharmacy Actions

Prior Authorization

Prior authorization required for non-formulary/restricted medications

If a member requires a drug not on their formulary, including non-formulary OTC drugs or medications with restrictions, providers must submit a prior authorization to obtain approval before prescribing or dispensing.

Prior Authorization

Pharmacy prior authorization before override/dispense

Dispensing pharmacies serving assisted living and long-term care facilities may request that a prior authorization be submitted for drugs with utilization management restrictions (including nonformulary and OTC drugs) prior to placing an override and dispensing the medication.

Documentation Required

Use of Neighborhood formularies when creating drug treatment plans

Providers are expected to utilize Neighborhood drug formularies when creating drug treatment plans for members in assisted living and long-term care facilities.

Operational note: This bulletin does not include any updated codes, coverage decision trees, or quantity/step therapy thresholds. Providers and pharmacies should continue to submit prior authorizations per Neighborhood’s established plan processes when a drug is non-formulary, OTC, or subject to utilization management restrictions.

Context

Neighborhood Health Plan of Rhode Island asks provider partners to follow plan formularies when treating members in assisted living and long-term care facilities. If a member requires a drug not on their formulary, including non-formulary OTC drugs or medications with restrictions, providers must submit a prior authorization to obtain approval prior to prescribing or dispensing to ensure safe and cost-effective treatment.