CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacy Benefit — Medicaid Drug Rebate Program Eligibility

Defines that Medicaid claims are payable only for drugs manufactured or distributed by labelers participating in the federal Medicaid Drug Rebate Program and describes Neighborhood Health Plan of Rhode Island's rejection of non‑participating manufacturers' products; applies to Neighborhood's Medicaid line of business and retail pharmacies processing claims.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit — Medicaid Drug Rebate Program Eligibility

Policy CodePolicy N/A

Change TypeProducts removed from Medicaid coverage

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionRetail pharmacies must reprocess claims for generics using a manufacturer that participates in the Medicaid rebate agreement; prescribers should identify covered alternatives for brand‑name medications.

SourceLink

POLICY UPDATE CHANGES

Effective October 1, 2025, the listed products will be excluded from Neighborhood's Medicaid coverage because their manufacturers will no longer participate in the Medicaid Rebate Program.

5specific products excluded from Medicaid coverage

Oct 1, 2025effective date for exclusions

Medicaid onlyline of business affected

Medicaid Rebate Participation Requirements

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit — Medicaid Drug Rebate Program Eligibility

Policy CodePolicy N/A

Change TypeProducts removed from Medicaid coverage

Effective DateOct 1, 2025

Next Review DateN/A

SourceLink

On This Page

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Medicaid rebate participation criteria

Coverage is contingent on manufacturer participation in the federal Medicaid Drug Rebate Program. Effective October 1, 2025, specific products will be excluded from Neighborhood's Medicaid coverage due to non‑participation.

ALL of the following

Manufacturer participation
- Manufacturer/labeler is enrolled in a rebate agreement with the U.S. Department of Health and Human Services (HHS). Claims for drugs from such manufacturers are eligible for Medicaid billing and payable under Neighborhood's Medicaid line of business.
- Manufacturer/labeler is NOT enrolled in a rebate agreement with HHS. Neighborhood will reject retail pharmacy claims for medications produced by manufacturers that have not entered into a rebate agreement with HHS; such products are excluded from Medicaid coverage effective October 1, 2025.
Product-specific exclusion: Effective October 1, 2025, the following products will be excluded from Neighborhood's Medicaid coverage because their manufacturers will no longer participate in the Medicaid Rebate Program: Cromolyn Spray 5.2/ACT; Relistor Tablet 150MG; Trulance Tablet 3MG; Xifaxan Tablet 550MG; Xifaxan Tablet 200MG.
Pharmacy and prescriber actions
- For brand‑name medications: prescribers should identify and prescribe a comparable covered alternative for the member.
- For generic medications: dispensing pharmacies should reprocess the claim using the same product from a manufacturer that participates in the rebate agreement; Neighborhood will reject retail pharmacy claims for non‑participating manufacturers' products.
Requirement applies to Neighborhood's Medicaid line of business only; it does not apply to Neighborhood's Commercial or Medicare plans.

ref": "b0_0

title": "Medicaid rebate participation criteria

Affected Products and Manufacturer Participation

Affected products (by name)NDCNot Covered

Cromolyn Spray 5.2/ACT	Cromolyn Spray 5.2/ACT
Relistor Tablet 150MG	Relistor Tablet 150MG
Trulance Tablet 3MG	Trulance Tablet 3MG
Xifaxan Tablet 550MG	Xifaxan Tablet 550MG
Xifaxan Tablet 200MG	Xifaxan Tablet 200MG

Manufacturer rebate participation (inv-03)

Policy requirementClaims are payable only for drugs manufactured or distributed by labelers participating in a rebate agreement with the U.S. Department of Health and Human Services (HHS).

Enforcement actionNeighborhood will reject retail pharmacy claims for medications produced by manufacturers that have not entered into a rebate agreement with HHS.

ScopeApplies to both brand-name and generic medications under Neighborhood's Medicaid line of business (does not apply to Neighborhood's Commercial or Medicare plans).

Pharmacy instruction for genericsDispensing pharmacies should reprocess the claim using the same product from a manufacturer that participates in the rebate agreement.

Prescriber instruction for brand-nameFor brand-name medications, identify and prescribe a comparable alternative for the member if the manufacturer is not participating.

Pharmacy Claim Processing and Prescriber Actions

Billing Rule

Pharmacy reprocessing and prescriber substitution for rebate participation

Retail pharmacies must reprocess claims for generic medications using a manufacturer/labeler that participates in the HHS Medicaid Drug Rebate Program; Neighborhood will reject retail pharmacy claims for medications produced by manufacturers that have not entered into a rebate agreement with HHS. For brand-name medications, prescribers must identify and prescribe a comparable covered alternative for the member.

Reprocess generic-product claims using the same product from a manufacturer participating in the rebate agreement.
Do not submit claims for drugs from manufacturers not in the HHS rebate agreement — such retail pharmacy claims will be rejected.
For brand-name products, prescribers must select and prescribe a comparable alternative listed on Neighborhood's Medicaid Formulary.

Terminology — Rebate Agreement Participation

Rebate agreement participation (inv-05)

DefinitionMedicaid Drug Rebate Program participation is enrollment of a drug manufacturer/labeler in a rebate agreement with the U.S. Department of Health and Human Services (HHS).

Effect on billing eligibilityOnly drugs from labelers participating in a rebate agreement with HHS are eligible for Medicaid billing under this policy.

Operational implicationManufacturers not in the rebate agreement will have their products excluded from Neighborhood's Medicaid coverage (effective dates listed where applicable).

Related provider actionsPharmacies must reprocess generics using a participating manufacturer; prescribers must select covered alternatives for brand-name products when manufacturer participation is lacking.

ApplicabilityRequirement does not apply to Neighborhood's Commercial or Medicare plans—only to Medicaid.