CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacy Benefit — Medicaid Drug Rebate Program

Governs billing eligibility for Medicaid pharmacy claims; only medications from manufacturers participating in the DHHS Medicaid Drug Rebate Program may be billed. Affects Medicaid pharmacy providers and retail pharmacies filling Neighborhood members' prescriptions.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit — Medicaid Drug Rebate Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRetail pharmacies must reprocess Medicaid claims for generics using a manufacturer participating in the DHHS rebate program and identify comparable alternatives for brand products when the original manufacturer is not a rebate participant.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 reqBillable requirement

brand & genericApplies to

Commercial/INTEGRITYExclusions

Medicaid Drug Rebate Billing Requirements

Medicaid drug rebate billing criteria

Claims policy for Medicaid pharmacy products relative to DHHS rebate participation:

Only medications manufactured or distributed by labelers participating in a DHHS rebate agreement are eligible to be billed under Medicaid.

Neighborhood will reject retail pharmacy claims for medications produced by manufacturers who have not entered into a rebate agreement with DHHS.

ALL of the following

If brand-name product: Identify and prescribe a comparable alternative for the member if the original manufacturer is not a rebate participant.
If generic product: The dispensing pharmacy should reprocess the claim using the same product from a manufacturer that participates in the rebate agreement.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit — Medicaid Drug Rebate Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

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Claim Rejection and Reprocessing Instructions

Denial Risk

Claim Rejection and Reprocessing Requirements

Neighborhood will reject retail Medicaid pharmacy claims for medications manufactured or distributed by companies that have not entered into a rebate agreement with the U.S. Department of Health and Human Services (DHHS). This requirement applies to both brand-name and generic products. It does not apply to Neighborhood commercial plans or INTEGRITY Medicare‑Medicaid plans.

Retail pharmacy Medicaid claims will be rejected if the medication’s manufacturer/labeler is not participating in the DHHS Medicaid Drug Rebate Program.
For brand‑name prescriptions: identify and prescribe a comparable alternative that is manufactured by a labeler participating in the DHHS rebate program.
For generic prescriptions: the dispensing pharmacy should reprocess the claim for the same generic product from a manufacturer who participates in the DHHS rebate agreement.

Key Definitions

Manufacturer participation in a rebate agreement with DHHS

DefinitionManufacturer participation in a rebate agreement with DHHS = enrollment in the DHHS Medicaid Drug Rebate Program making their manufactured or distributed products eligible to be billed under Medicaid.

Billing requirementOnly medications manufactured or distributed by labelers participating in a DHHS rebate agreement are eligible to be billed under Medicaid.

Operational impactNeighborhood will reject retail pharmacy claims for medications produced by manufacturers who have not entered into a rebate agreement with DHHS.

Brand-name prescriptionsIf the prescribed product is a brand-name medication from a non-participating manufacturer, identify and prescribe a comparable alternative for the member.

Generic prescriptionsIf the prescribed product is a generic medication from a non-participating manufacturer, the dispensing pharmacy should reprocess the claim using the same product from a manufacturer that participates in the rebate agreement.

Scope exclusionThis requirement does not apply to Neighborhood's Commercial or INTEGRITY MedicareMedicaid plans.