CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid Non-Formulary Quantity Limits (drug-specific)

A list of non-formulary drug-specific quantity limits (approved quantities, daily limits, and target GPIs) that govern Medicaid pharmacy dispensing for Neighborhood Health Plan of Rhode Island; affects pharmacy benefit adjudication for members and providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Non-Formulary Quantity Limits (drug-specific)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionApply the listed product-specific approved quantities and daily limits when adjudicating Medicaid pharmacy claims for non-formulary drugs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+drug entries shown (partial)

variedtime windows

yesincludes Target GPI

13+ pagesdocument excerpt length

Product-specific Quantity Rules

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.

ALL of the following

Drug: 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

ALL of the following

Drug: ACYCLOVIR 5% CREAM
Approved quantity: 5 gm per 30 days
Daily limit (quantity per day): n/a
Target GPI: 90350010003720

ALL of the following

Drug: AFINITOR TAB 10MG
Approved quantity: 30 per 30 days
Daily limit (quantity per day): 1
Target GPI: 21532530000330

Per-product quantity limits (examples)

Per‑product quantity limits and associated identifiers as listed in this excerpt.

ALL of the following

Product: RASUVO PEN 12.5MG/0.25ML
Limit: 2 cartridges per 28 days = 4 injections per 28 days
Identifiers: 0.0720; 3004405510E110; 6625005000D517

ALL of the following

Product: RASUVO PEN 15MG/0.3ML
Limit: 2 cartridges per 28 days = 4 injections per 28 days
Identifiers: 0.0720; 3004405510E110; 6625005000D519

ALL of the following

Product: STELARA VIAL 130 MG/26 ML
Limit: 1 dose (up to 520 mg/104 ml) per 365 days
Identifiers: 6240306045E560; 52504070002020

ALL of the following

Product: SOVALDI TAB 400MG
Limit: 28 per 28 days
Identifiers: 6240306045E560; 12353080000320

ALL of the following

Product: ZTLIDO 1.8% PATCH
Limit: 90 patches per 30 days
Identifiers: 90850060005910

Identifiers, GPIs, and Code Examples

Sample Target GPIs includedmixed

6650007000E520	ACTEMRA INJ 162MG/0.9ML Target GPI (example)
90350010003720	ACYCLOVIR 5% CREAM Target GPI (example)

examples of listed product identifiers / NDC-like codesmixed

3004405510E110	product identifier displayed alongside RASUVO PEN entries
6240306045E560	product identifier used frequently for multiple entries
21533070300140	product identifier appearing in many entries
12105005102020	product identifier for ZIAGEN SOL 20MG/ML

AURYXIA limits

AURYXIA monthly limit360 per 30 days

AURYXIA daily limit12 (Quantity per day)

AURYXIA Target GPI52800030100320

BUPHENYL limits

BUPHENYL monthly limit1200 per 30 days

BUPHENYL daily limit40 (Quantity per day)

BUPHENYL Target GPI30908060000320

Common period thresholds

Common periods usedPer 28 days or per 30 days (most entries)

Examples per 28 daysRASUVO PEN entries: 2 cartridges per 28 days = 4 inj per 28 days

Examples per 30 daysVIREAD/ZIAGEN/SUSTIVA examples: 30 per 30 days or 90 per 30 days

What Providers Must Know / Do

Billing Rule

Provider action: Quantity limit entries (example)

Medicaid Non‑Formulary Quantity Limits — Examples of provider-facing quantity limits and daily limits for specific non‑formulary products. Review these limits when submitting claims to avoid denials or edits.

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 ACTPEN 162MG/0.9ML — Approved Quantity: 4 autoinjectors (3.6 ml) per 28 days. Daily Limit: 0.13. Target GPI: 6650007000D520.
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.
ACYCLOVIR 5% CREAM — Approved Quantity: 5 gm per 30 days. Daily Limit: n/a. Target GPI: 90350010003720.
ALBENZA TAB 200MG — Approved Quantity: 4 tabs per fill. Daily Limit: n/a. Target GPI: 15000002000320.
AFINITOR TAB 10MG — Approved Quantity: 30 per 30 days. Daily Limit: 1.

Billing Rule

Provider action: Quantity limit entries (cartridge/injection examples)

Some products have quantity expressed as cartridges per 28 days mapped to injections per period and corresponding daily limits; ensure dispensed quantity aligns with the stated per‑period and per‑day limits.

RASUVO PEN 7.5MG/0.15ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.022. Target GPI: 6625005000D5?? (mapping from source).
RASUVO PEN 12.5MG/0.25ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.036. Target GPI: 6625005000D517.
RASUVO PEN 15MG/0.3ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.043. Target GPI: 6625005000D519.
RASUVO PEN 17.5MG/0.35ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.05. Target GPI: 6625005000D522.
RASUVO PEN 20MG/0.4ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.058. Target GPI: 6625005000D525.
RASUVO PEN 22.5MG/0.45ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.065. Target GPI: 6625005000D527.
RASUVO PEN 25MG/0.5ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.072. Target GPI: 6625005000D535.
RASUVO PEN 30MG/0.6ML — 2 cartridges per 28 days = 4 inj per 28 days. Daily Limit: 0.086. Target GPI: 6625005000D545.

Billing Rule

Provider action: Annual / per‑period limit examples

Annual and per‑period limits are specified for certain injectables and tablets — verify the allowed doses per 28/30/365 days and corresponding daily quantity value when prescribing or billing.

SIGNIFOR 0.6 mg/ml — quantity factor 0.15 = 2 (per applicable period). Target mapping: 6240306045E560 / 6240306045D560 = 30170075202030.
SIGNIFOR 0.9 mg/ml — 12 (4.2 ml) per 28 days = 60 per 30 days. Quantity factor 0.15 = 2. Target mapping: 6240306045E560 / 6240306045D560 = 30170075202040.
SOMAVERT INJ (10/15/20/25/30MG) — 12 (4.2 ml) per 28 days = 30 per 30 days. Quantity factor 0.15 = 1. Target mapping: 6240306045E560 / 6240306045D560 with respective NDCs 30180060002120, 30180060002130, 30180060002140, 30180060002150, 30180060002160.
SOVALDI TAB 400MG — 12 (4.2 ml) per 28 days = 28 per 28 days. Quantity factor 0.15 = 1. Target mapping: 6240306045E560 / 6240306045D560 = 12353080000320.

Key Terms and Field Formats

Approved Quantity

Approved Quantity (definition)The product-specific maximum quantity authorized for the indicated period (e.g., "Approved Quantity = 162 mg per week (3.6 ml) per 28 days").

ExamplesACTEMRA INJ 162MG/0.9ML: 162 mg per week (3.6 ml) per 28 days; BRIVIACT TAB 10MG: 120 per 30 days

PurposeUsed to adjudicate pharmacy claims against product-level quantity limits

Daily Limit

Daily Limit (Quantity per day)Maximum quantity allowed per day for a product (e.g., ACTEMRA INJ 162MG/0.9ML: 0.13).

ExamplesAURYXIA TAB 210MG: 12 per day; BRIVIACT ORAL SOL 10MG/ML: 20 per day; BUPHENYL TAB 500MG: 40 per day

When not applicableSome products list 'n/a' for daily limit (e.g., ACYCLOVIR 5% CREAM)

Target GPI

Target GPI (identifier)Product-level GPI code used to map adjudication rules (e.g., ACTEMRA INJ 162MG/0.9ML: 6650007000E520).

Examples includedACTEMRA 6650007000E520; ACYCLOVIR 90350010003720; AURYXIA 52800030100320

FormatAlphanumeric codes shown alongside product entries in the document

Quantity limit entry format

Quantity limit formatEntries may show both item count and equivalent units for the period (example: "2 cartridges per 28 days = 4 inj per 28 days").

Product exampleRASUVO PEN 12.5MG/0.25ML: 2 cartridges per 28 days = 4 inj per 28 days

Alternate exampleSPRYCEL TAB 50MG: 12 (4.2 ml) per 28 days = 30 per 30 days

Annual limit

Annual limit (definition)A maximum quantity specified over a 365-day period (e.g., STELARA VIAL 130 MG/26 ML = 1 dose per 365 days).

ExampleSTELARA VIAL 130 MG/26 ML: 1 dose (up to 520 mg/104 ml) per 365 days

Other usesSome products list annual totals for chronic/long-duration therapies (e.g., BRYHALI LOT 0.01%: 400 gm per 365 days)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Non-Formulary Quantity Limits (drug-specific)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionApply the listed product-specific approved quantities and daily limits when adjudicating Medicaid pharmacy claims for non-formulary drugs.

SourceLink

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