CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacy Benefit Medicaid Drug Rebate Program Billing Eligibility

This document governs billing eligibility for Medicaid pharmacy claims at Neighborhood Health Plan of Rhode Island, requiring drugs be from manufacturers participating in the federal Medicaid Drug Rebate Program; it affects retail pharmacies submitting Medicaid claims to Neighborhood (does not apply to Commercial or INTEGRITY plans).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit Medicaid Drug Rebate Program Billing Eligibility

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRetail pharmacies must not bill Medicaid for drugs from manufacturers not participating in the DHHS Medicaid Drug Rebate Program; claims will be rejected and should be reprocessed using a participating manufacturer's product or prescriber should select an alternative.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Manufacturer participation requirement

rejectedNon-participating action

brand & genericApplies to

excludedCommercial/INTEGRITY

Medicaid Billing Eligibility Criteria

Medicaid drug rebate participation criteria

Eligibility and actions for Medicaid pharmacy claims:

Manufacturer participates in DHHS Medicaid Drug Rebate Program

Applies to brand-name and generic products

Only drugs manufactured or distributed by labelers participating in a drug rebate agreement with the U.S. Department of Health and Human Services (DHHS) are eligible to be billed under Medicaid

If manufacturer does NOT participate

Retail pharmacy claims for medications produced by manufacturers who have not entered into a DHHS drug rebate agreement will be rejected by Neighborhood Health Plan of Rhode Island
For brand-name prescriptions: prescriber should identify and prescribe a comparable alternative for the member

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit Medicaid Drug Rebate Program Billing Eligibility

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

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Billing, Rejection, and Reprocessing Requirements

Billing Rule

Reject and reprocess Medicaid retail pharmacy claims for non‑rebate manufacturers

Neighborhood will reject retail Medicaid pharmacy claims for medications manufactured or distributed by labelers that have not entered into a drug rebate agreement with the U.S. Department of Health and Human Services. For brand-name prescriptions, prescribers should identify and prescribe a comparable alternative; for generic prescriptions, the dispensing pharmacy should reprocess the claim using the same product from a participating manufacturer.

Do not submit Medicaid retail pharmacy claims for products from non‑participating labelers — such claims will be rejected.
For brand‑name prescriptions: prescriber must identify and prescribe a comparable alternative that is made by a participating manufacturer.
For generic prescriptions: dispensing pharmacy must reprocess the claim using the same generic product sourced from a manufacturer participating in the DHHS rebate agreement.
This requirement applies to both brand and generic medications and does not apply to Neighborhood’s Commercial or INTEGRITY plans.

Definitions

Participating manufacturer — definition

DefinitionDrugs manufactured or distributed by labelers participating in a drug rebate agreement with the United States Department of Health and Human Services (DHHS).

RelevanceParticipation is required for Medicaid billing eligibility for both brand and generic products.

Policy sourceMandated by the Centers for Medicare & Medicaid Services and enforced by Neighborhood Health Plan of Rhode Island.

Non-participating manufacturer billing — claim rejection and reprocessing

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

Brand-name prescription guidanceIf the prescribed product is a brand-name medication, prescribers should identify and prescribe a comparable alternative for the member.

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

OpenPayer

Pharmacy Benefit Medicaid Drug Rebate Program Billing Eligibility

Medicaid Billing Eligibility Criteria

Coding and Manufacturer Participation

Billing, Rejection, and Reprocessing Requirements

Definitions