CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior authorization requirements for drugs in assisted living and long-term care

Governs prior authorization and formulary use for Neighborhood Health Plan of Rhode Island members residing in assisted living and long-term care facilities; affects providers and dispensing pharmacies when prescribing or dispensing restricted or non‑formulary medications.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior authorization requirements for drugs in assisted living and long-term care

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit a prior authorization when a required drug is not on the member's formulary or has a restriction.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1document chunks summarized

assisted living & LTCsettings referenced

PA requiredaction emphasized

Coverage Criteria

Prior Authorization Requirement

Covered when ALL of the following are met

Prior authorization for non-formulary/restricted drugs: Provider has submitted a prior authorization to Neighborhood for drugs not on the member's formulary, including non-formulary over-the-counter (OTC) drugs, or for medications that have a utilization management restriction.

Applies to members residing in assisted living and long-term care facilities; dispensing pharmacies in these settings may request prior authorization before overriding utilization management restrictions.

No explicit clinical exclusions are listed in this document.

The document does not define any not medically necessary conditions.

Coding

No codes listedmixed

No codes listed

Coding — inventory

Coding status

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior authorization requirements for drugs in assisted living and long-term care

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit a prior authorization when a required drug is not on the member's formulary or has a restriction.

SourceLink

On This Page

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.

Provider Actions / Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for drugs not on the member's formulary, non‑formulary over‑the‑counter (OTC) drugs, and medications that have a utilization management restriction. Providers should consult Neighborhood’s current formularies (available on the payer website) when developing drug treatment plans for members in assisted living and long‑term care facilities.

Note

Provider Coordination Required

Providers caring for Neighborhood members in assisted living or long‑term care settings must coordinate with Neighborhood prior to dispensing or administering non‑formulary or restricted medications. This includes working with the member’s pharmacy if the pharmacy requests a prior authorization before overriding a restriction to dispense a medication.

Prior Authorization

Prior Authorization Submission

Providers must submit a prior authorization request to Neighborhood when a required drug is not on the member's formulary, when a non‑formulary OTC drug is needed, or when a medication is subject to a utilization management restriction. Follow Neighborhood’s prior authorization submission process and include clinical justification and supporting documentation to facilitate review.

Denial Risk

Risk of Non‑Approval if PA Not Obtained

If prior authorization is not obtained when required, the drug may be denied or the dispensing pharmacy may be unable to override the restriction, which can delay or prevent the member from receiving the medication. To avoid denial or dispensing delays, obtain prior authorization before dispensing non‑formulary, OTC non‑formulary, or restricted medications.

Definitions

Formulary (definition)

DefinitionFormulary: the payer's list of covered drugs used to guide treatment plans.

PurposeGuides provider prescribing and helps ensure members receive safe, cost‑effective treatment options.

MaintenanceProviders should refer to the most up‑to‑date versions of Neighborhood formularies listed by line of business on the payer website.

Prior authorization (definition)

DefinitionPrior authorization: the process by which providers work with Neighborhood to obtain approval before dispensing a non‑formulary or restricted medication.

When requiredRequired for drugs not on the member's formulary, non‑formulary over‑the‑counter (OTC) drugs, and medications that have utilization management restrictions for members in assisted living and long‑term care.

Provider actionProviders must submit a prior authorization request to Neighborhood to request approval when the required drug is not on the member's formulary or has a restriction.

Pharmacy practiceDispensing pharmacies in assisted living and long‑term care may request a prior authorization before placing an override and dispensing medications with utilization management restrictions.

OpenPayer

Prior authorization requirements for drugs in assisted living and long-term care

Coverage Criteria

Coding

Provider Actions / Requirements

Background

Definitions

Site of Care / Applicability