Pharmacy Benefit: Medicaid Drug Rebate Program (MDRP) billing eligibility
Governs billing eligibility for pharmacy claims under Neighborhood Health Plan of Rhode Island's Medicaid line: only drugs from manufacturers with DHHS drug rebate agreements may be billed; affects retail pharmacies and prescribers for Medicaid members (does not apply to Commercial or INTEGRITY MMP).
No material clinical or coverage changes in this revision.
Medicaid Drug Rebate Program Billing Eligibility
MDRP billing criteria and workflows
Coverage criteria for pharmacy claims under Neighborhood Medicaid:
If brand-name medication:
- Prescriber must identify and prescribe a comparable alternative from a manufacturer participating in the DHHS rebate agreement.
If generic medication:
- Dispensing pharmacy must reprocess the claim using the same product from a manufacturer participating in the DHHS rebate agreement.
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