CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid Non-Formulary Quantity Limits

A listing of approved quantity limits and daily limits for non‑formulary medications under Neighborhood Health Plan of Rhode Island's Medicaid program; applies to drugs and formulations shown in this document extract.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Non-Formulary Quantity Limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed approved quantity and daily limits for each non‑formulary drug when processing Medicaid pharmacy claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks included

17chunks provided

includes GPIincludes GPI codes

manyincludes daily limits

Quantity Limits and Coverage Criteria

Quantity limits (example node)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Non-Formulary Quantity Limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed approved quantity and daily limits for each non‑formulary drug when processing Medicaid pharmacy claims.

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.

Product Identifiers and Coding

Target GPI / internal product identifiers (examples)mixed

6650007000E520	ACTEMRA INJ 162MG/0.9ML Target GPI
72600015000310	BRIVIACT TAB 10MG Target GPI
3004405510E110	Example NATPARA/NORVIR/NURTEC/OLUMIANT/OPIPZA/ORENCIA related identifier

Sample drug identifiers (NDC/plan codes)mixed

3004405510E120	Example pack/identifier for NATPARA INJ 50 MCG (as listed)
12104560000320	Identifier listed for NORVIR TAB 100MG

Example daily limit — BRIVIACT ORAL SOL 10MG/ML

Drug / FormulationBRIVIACT ORAL SOL 10MG/ML

Daily limit (ml per day)20 ml per day

Source contextListed as an example daily limit in the Medicaid Non-Formulary Quantity Limits table

PRADAXA CAP 75 MG limit

Drug / FormulationPRADAXA CAP 75 MG

Approved quantity (30 days)60 per 30 days

Equivalent cadence2 cartridges per 28 days (document lists both representations)

Provider Actions and Operational Notes

Billing Rule

Quantity limit table (partial)

Provides approved quantity and daily limits for listed non‑formulary medications. Example: ACTEMRA INJ 162MG/0.9ML — Approved Quantity = 162 mg per week (3.6 ml) per 28 days; Daily Limit (Quantity per day) = 0.13; Target GPI = 6650007000E520. Several other ACTEMRA formulations list approved quantities per 14 or 28 days and corresponding daily limits as shown in the table.

ACTEMRA INJ 162MG/0.9ML — Approved Quantity: 162 mg per week (3.6 ml) per 28 days; Daily Limit = 0.13; Target GPI = 6650007000E520.
ACTEMRA INJ 200MG/10ML — Approved Quantity: 40 ml per 14 days; Daily Limit = 2.86; Target GPI = 66500070002035.
ACTEMRA INJ 400MG/20ML — Approved Quantity: 40 ml per 14 days; Daily Limit = 2.86; Target GPI = 66500070002040.
ACTEMRA INJ 80MG/4ML — Approved Quantity: 40 ml (10 vials) per 14 days; Daily Limit = 2.86; Target GPI = 66500070002030.
ACTEMRA ACTPEN 162MG/0.9ML — Approved Quantity: 4 autoinjectors (3.6 ml) per 28 days; Daily Limit = 0.13; Target GPI = 6650007000D520.

Billing Rule

Medicaid Non-Formulary Quantity Limits (sample)

Enumerates Medicaid non‑formulary drugs with their allowed quantity over the specified period. Example: NATPARA INJ 50 MCG (2 cartridges) — 2 cartridges per 28 days; NATPARA INJ 75 MCG (2 cartridges) — 2 cartridges per 28 days. Other listed products (e.g., NORVIR, NURTEC, OLUMIANT) include their per‑period limits and identifiers.

NATPARA INJ 50 MCG (2 CARTRIDGES) — 2 cartridges per 28 days; identifier listed = 3004405510E120.
NATPARA INJ 75 MCG (2 CARTRIDGES) — 2 cartridges per 28 days; identifier listed = 3004405510E130.
NORVIR TAB 100MG — 360 per 30 days; identifier listed = 12104560000320.
NORVIR POWD PKT 100MG — 360 per 30 days; identifier listed = 12104560003020.
NURTEC TAB 75MG ODT — 18 per 30 days; identifier listed = 67701060707220.
OLUMIANT TAB 1MG/2MG — 30 per 30 days; identifiers listed = 66603010000310 / 66603010000320.

Key Terms and Definitions

Approved Quantity (per drug/formulation)

Typical expressionApproved Quantity is listed per drug/formulation, often expressed per 28 or 30 days (e.g., ACTEMRA INJ 162MG/0.9ML = 162 mg per week (3.6 ml) per 28 days).

Examples from documentBRIVIACT TAB 10MG = 120 per 30 days; NATPARA INJ 50 MCG = 2 cartridges per 28 days; PRADAXA CAP 75 MG = 60 per 30 days.

PurposeDefines the maximum approved amount dispensed for the specified refill/window period.

Daily Limit (Quantity per day)

DefinitionDaily Limit = Quantity per day (numeric value shown next to many entries).

ExamplesACTEMRA INJ 162MG/0.9ML Daily Limit = 0.13; BRIVIACT TAB 10MG Daily Limit = 4; PRADAXA CAP 75 MG Daily Limit = 2.

UsageUsed to restrict dispensing to a per-day average when approved quantity is expressed over 28/30 days.

Target GPI (internal product identifiers)

What it isTarget GPI is the internal product identifier included for many entries in the quantity limits table.

ExamplesACTEMRA INJ 162MG/0.9ML = 6650007000E520; BRIVIACT TAB 10MG = 72600015000310; PRADAXA CAP 75 MG = 83337030200120.

PurposeEnables matching of plan-specific product records to the listed quantity rules.

Quantity limits (maximum dispensed amount over specified period)

DefinitionQuantity limits = maximum dispensed amount over a specified period (e.g., per 28 days or per 30 days) as listed next to each drug.

Representative limitsBRIVIACT TAB 10MG = 120 per 30 days; BRIVIACT TAB 25/50/75/100MG = 60 per 30 days (for several strengths); NATPARA INJ 50 MCG = 2 cartridges per 28 days; PRADAXA CAP (75/110/150 mg) = 60 per 30 days.

Typical periodsMost entries use 28-day or 30-day windows; some specify per week or per fill as shown in the table.