CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacy Benefit Medicaid Drug Rebate Program Reminder

Governance of which outpatient pharmacy drugs can be billed to Neighborhood Health Plan of Rhode Island Medicaid benefits — applies to retail pharmacy claims for Medicaid members only. Affects prescribers, dispensing pharmacies, and claims processors.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit Medicaid Drug Rebate Program Reminder

Policy CodePolicy N/A

Change TypePolicy reminder

Effective Date

Next Review Date

Key ActionPrescribers should identify alternative brand products from manufacturers participating in the DHHS Medicaid Drug Rebate Program and dispensing pharmacies should reprocess claims using products from participating manufacturers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1policy reminder bulletin in Neighborhood News (Jan 2025)

1payer affected

2types of products affected

0applies to Commercial or INTEGRITY MedicareMedicaid plans

Medicaid Rebate Billing Eligibility

Medicaid rebate participation billing criteria

Covered/billing stance for outpatient retail pharmacy claims under Neighborhood Medicaid:

Drug must be manufactured or distributed by a labeler participating in a rebate agreement with the U.S. Department of Health and Human Services (DHHS) to be billable under Neighborhood Medicaid.

ALL of the following

If brand-name:: Prescriber should identify and prescribe a comparable alternative from a participating labeler.
If generic:: Dispensing pharmacy should reprocess the claim using the same product from a manufacturer participating in the rebate agreement.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit Medicaid Drug Rebate Program Reminder

Policy CodePolicy N/A

Change TypePolicy reminder

Effective Date

Next Review Date

SourceLink

On This Page

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NDC and Manufacturer Participation Requirements

NDC manufacturer participation requirementNDC

No codes listed

Manufacturer rebate agreement — billing requirement (Medicaid)

RequirementDrug must be manufactured or distributed by a labeler participating in a DHHS Medicaid Drug Rebate Program agreement to be billed under Medicaid.

ScopeApplies to retail pharmacy claims for Medicaid members (both brand-name and generic medications).

Provider action — brand-nameIf prescribed product is brand-name, prescriber should identify and prescribe a comparable alternative from a participating labeler.

Provider action — genericIf prescribed product is generic, dispensing pharmacy should reprocess the claim using the same product from a manufacturer participating in the rebate agreement.

ExclusionRequirement does not apply to Neighborhood's Commercial or INTEGRITY MedicareMedicaid plans.

Claims Processing and Pharmacy Responsibilities

Denial Risk

Claim rejection and provider actions — retail pharmacy claims for Medicaid

Retail pharmacy claims for Medicaid will be rejected if the drug manufacturer/labeler is not a participant in the DHHS Medicaid Drug Rebate Program. This applies to both brand-name and generic products. Action required: prescribers and pharmacies must ensure the dispensed product is from a participating labeler to avoid claim denial.

Medicaid retail pharmacy claims will be rejected for drugs from manufacturers not in the DHHS Medicaid Drug Rebate Program.
For brand-name prescriptions: prescribers should identify and prescribe a comparable alternative that is produced by a rebate-participating manufacturer.
For generic prescriptions: the dispensing pharmacy should reprocess the claim using the same generic product from a manufacturer that participates in the rebate agreement.
This requirement does not apply to Neighborhood's Commercial or INTEGRITY MedicareMedicaid plans.

OpenPayer

Pharmacy Benefit Medicaid Drug Rebate Program Reminder

Medicaid Rebate Billing Eligibility

NDC and Manufacturer Participation Requirements

Claims Processing and Pharmacy Responsibilities

Key Terms