Pharmacy Benefit Medicaid Drug Rebate Program
This policy governs billing eligibility for Medicaid pharmacy claims at Neighborhood Health Plan of Rhode Island, requiring that drugs be manufactured or distributed by labelers with a DHHS drug rebate agreement; it affects retail pharmacies submitting Medicaid claims (does not apply to Neighborhood Commercial or INTEGRITY MedicareMedicaid plans).
No material clinical or coverage changes in this revision.
Medicaid Billing Eligibility
Medicaid drug rebate billing criteria
Covered/billable under Medicaid only when ALL of the following criteria are met:
ALL of the following
- The drug is manufactured or distributed by a labeler that has an active drug rebate agreement with the U.S. Department of Health and Human Services (DHHS).
ALL of the following
- If brand-name: If the prescribed product is a brand-name medication from a non-participating manufacturer, the prescriber must identify and prescribe a comparable alternative from a participating labeler.
- If generic: If the prescribed product is a generic medication from a non-participating manufacturer, the dispensing pharmacy must reprocess the claim using the same product from a manufacturer that participates in the DHHS rebate agreement.
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