CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Therapy Criteria Form for Pharmacy Step Therapy

A form and instructions for prescribers to request coverage or prior authorization for prescription therapies under Neighborhood Health Plan of Rhode Island, including step-therapy documentation and expedited decision option. Affects participating physicians/providers submitting requests on behalf of members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTherapy Criteria Form for Pharmacy Step Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed form to Neighborhood at 1-866-423-0945 to request coverage and include documentation of prior trials or contraindications when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-423-0945fax number for submission

401-427-8200pharmacy department phone

24hexpedited decision timeframe

Cover My Medsportal

Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTherapy Criteria Form for Pharmacy Step Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed form to Neighborhood at 1-866-423-0945 to request coverage and include documentation of prior trials or contraindications when applicable.

SourceLink

On This Page

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Primary requirements: 1) Completed form with patient and prescriber information; 2) Medication details including strength, route, frequency, new prescription or therapy initiation date, expected length of therapy, quantity, height/weight, and allergies; 3) Documentation that patient has tried and failed first-line formulary alternatives OR has intolerance/contraindication/expected adverse reaction (when applicable) with medication names and reasons for failure provided; 4) Prescriber signature and NPI

Provide dates and names of prior medications and reasons for failure/intolerance/contraindication. If step-therapy applies, attach supporting documentation.

inv-02: Continuation Therapy

Covered when ALL of the following are met

Continuation requirements: 1) Indicate this is a continuation of therapy and provide the start date of therapy; 2) Provide current medication details and any updated clinical rationale or outcome information (including adverse effects); 3) Include any additional documentation requested by the plan

Start date required if continuation requested. Use the form fields for therapy initiation date and clinical updates.

This coverage criteria form is used to evaluate requests for prescription therapies under Neighborhood Health Plan of Rhode Island when step-therapy rules may apply. Decisions are based on documented clinical information provided on the form, including patient and prescriber details, the medication requested (strength, route, frequency), whether the request is for initiation or continuation of therapy, and evidence of prior medication trials or documented contraindications/intolerances. Approval for initial therapy requires completion of the form and supporting documentation of prior formulary trials or a stated contraindication/intolerance; continuation therapy requires indication that the request is for ongoing treatment and the therapy start date. The form also includes a prescriber attestation with signature and NPI.

Requests that do not include required documentation may be considered not medically necessary. Specifically, if the form does not provide documentation showing that the patient tried and failed first-line formulary alternatives or provide documentation of intolerance, contraindication, or an expected adverse reaction, the request may be denied. When asserting a step-therapy exception, include the names of medications tried and the reason for failure, intolerance, or contraindication to support approval.

Coding and Contact Info

Submission contactmixed

1-866-423-0945

Fax number for submission (document-provided contact treated as a code for routing purposes)

Contact phonemixed

401-427-8200

Pharmacy Department Phone

inv-07: Expedited decision timeframe — 24 hours

Expedited decision timeframeIf the prescriber believes waiting for a standard decision could seriously harm life, health, or ability to function, a decision may be requested within 24 hours by checking the expedited decision box.

How to requestCheck the expedited decision box on the form to indicate need for a decision within 24 hours.

Criteria for useUsed when waiting for a standard decision could seriously harm the member's life, health, or ability to maximum function.

Provider Actions and Submission Requirements

Prior Authorization

Prior authorization submission

Fax the completed Step Therapy / Therapy Criteria form to Neighborhood Health Plan of Rhode Island at 1-866-423-0945. For real-time coverage determinations use Cover My Meds. Documentation of prior trials, failures, intolerances, contraindications, or expected adverse reactions is required for approval.

Fax: 1-866-423-0945
Pharmacy Dept. Phone: 401-427-8200
Real-time coverage: https://www.covermymeds.com/epa/caremark

Step Therapy

Step therapy requirement

Requests must confirm whether the patient has tried and failed first-line formulary alternatives for the diagnosis. If the answer is 'Yes', include documentation of the trial and reason for failure, intolerance, contraindication, or expected adverse reaction. Lack of step therapy documentation may result in denial.

Question: Has the patient tried and failed first-line formulary alternatives? (Yes/No)
If Yes — include documentation of medication(s) tried and reason for failure/intolerance/contraindication/expected adverse reaction
Requests without adequate step therapy documentation may be denied

Documentation Required

Step therapy documentation

Provide specific documentation of prior medication trials: list medication name(s), start and stop dates, dose, and the clinical reason the agent failed (inadequate response), was not tolerated, or is contraindicated.

Include medication name(s) tried
Provide reason for treatment failure, intolerance, or contraindication
Provide start and stop dates and doses when available

Documentation Required

Form fields required

Complete all required form fields on the Step Therapy / Therapy Criteria Form. Incomplete forms may delay processing.

Enrollee information: name, DOB, address, city, state, ZIP, phone, member ID
Prescriber information: prescriber signature, NPI, date
Medication details: medication name, strength, route, frequency, quantity
Prescription details: new prescription OR date therapy initiated, expected length of therapy
Clinical details: diagnosis, height/weight, allergies, additional clinical information

Denial Risk

Lack of step therapy documentation

If the form does not show prior trial and failure, intolerance, contraindication, or expected adverse reaction to first-line agents, the request may be denied. Ensure documentation is clear and specific.

Denial risk if step therapy documentation is missing or insufficient
Provide clear clinical notes or medication history supporting the stated reason

Background

The purpose of this form is to collect focused clinical and trial history to determine medical necessity under step-therapy rules. It asks whether the patient has tried and failed first-line formulary alternatives and, if so, requires documentation of the specific medication(s) tried and the reason(s) for inadequate response, intolerance, contraindication, or expected adverse reaction. This information allows reviewers to determine whether an exception to step therapy is warranted for initial or non‑formulary therapies.

Definitions

inv-14: trial and inadequate treatment response, intolerance, contraindication, or expected adverse reaction to first-line formulary alternatives — Step therapy failure definition

Definition (Step therapy failure)Trial and inadequate treatment response, intolerance, contraindication, or expected adverse reaction to first-line formulary alternatives.

Documentation requiredIf patient has tried and failed first-line formulary alternatives, provide documentation including name(s) of medication(s) tried and reason(s) for treatment failure, intolerance, or contraindication.

Form questionThe form asks whether the patient tried and failed first-line formulary alternatives for the given diagnosis with a Yes/No response; if Yes, documentation is required for approval.

Use for exceptionsThis definition is the basis for asserting a step therapy exception when requesting non-formulary or later-line therapy.

Initial Therapy Criteria

inv-15: Initial Therapy

Initial therapy requests require medication details and step therapy documentation when applicable

Initial therapy: Complete medication strength, route, frequency, new prescription or therapy initiation date, expected length of therapy, quantity, and patient height/weight; when patient has tried first-line formulary alternatives, document each medication name and provide the reason for failure, intolerance, or contraindication for each; include prescriber signature and NPI.

Form contains dedicated fields for medication details and free-text space to document prior trials and reasons for failure.

Continuation Criteria

inv-16: Continuation

Continuation requests must state prior start date and provide ongoing therapy details

Continuation: When submitting for ongoing therapy, indicate that this is a continuation, provide the original start date of therapy, current medication dosing (strength, route, frequency), and any clinical outcome or adverse effect information; include prescriber signature and NPI.

Form includes a specific question asking if this is a continuation and a field for the therapy start date.

Medication tried (name)	Reason for failure / intolerance / contraindication
[Enter name of medication tried]
[Enter reason: e.g., inadequate treatment response, documented intolerance, documented contraindication, or expected adverse reaction]

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