CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacy Benefit — Medicaid Drug Rebate Program Reminder

Governs billing eligibility for Medicaid pharmacy claims; limits reimbursable drugs to those from manufacturers participating in the DHHS Medicaid Drug Rebate Program and affects retail pharmacies processing Medicaid claims.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit — Medicaid Drug Rebate Program Reminder

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRetail pharmacy claims for Medicaid will be rejected if the medication's manufacturer is not a participant in the DHHS Medicaid Drug Rebate Program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1requirement applies to Medicaid pharmacy claims only

bothapplies to brand-name and generic medications

rejectretail pharmacy claims will be rejected if manufacturer not in DHHS rebate agreement

Medicaid Drug Rebate Billing Criteria

Medicaid drug rebate billing criteria

Eligibility criteria for Medicaid pharmacy reimbursement:

Drugs must be manufactured or distributed by labelers participating in a DHHS Medicaid Drug Rebate Program agreement (DHHS participation required).

If false, retail pharmacy claim will be rejected by Neighborhood.

Applies only to Medicaid pharmacy claims; does not apply to Neighborhood Commercial or INTEGRITY MedicareMedicaid plans.

When manufacturer is not participating: If the prescribed product is a brand-name medication, the prescriber must identify and prescribe a comparable alternative produced by a manufacturer participating in the rebate agreement.

When manufacturer is not participating: If 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.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit — Medicaid Drug Rebate Program Reminder

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRetail pharmacy claims for Medicaid will be rejected if the medication's manufacturer is not a participant in the DHHS Medicaid Drug Rebate Program.

SourceLink

On This Page

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Actions Required by Prescribers and Pharmacies

Note

Medicaid rebate requirement

As mandated by the Centers for Medicare & Medicaid Services, 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. Neighborhood Health Plan of Rhode Island (Neighborhood) will reject retail pharmacy claims for medications produced by manufacturers who have not entered into a DHHS drug rebate agreement. This requirement does not apply to Neighborhood's Commercial or INTEGRITY MedicareMedicaid plans.

Prior Authorization

Prescriber action for brand-name drugs

If the prescribed product is a brand-name medication from a manufacturer not participating in the DHHS rebate agreement, the prescriber should identify and prescribe a comparable alternative that is manufactured by a participating labeler.

Applicable to brand-name prescriptions where the current manufacturer is not in DHHS rebate agreement

Billing Rule

Pharmacy reprocessing for generics

For generic medications dispensed by retail pharmacies where the original manufacturer is not participating in the DHHS rebate agreement, the dispensing pharmacy must reprocess the claim using the same generic product from a manufacturer that does participate in the rebate agreement. Retail pharmacy claims for non‑rebate manufacturers will be rejected.

Reprocess claim using the same generic but from a participating manufacturer
Retail pharmacy claims for non-rebate manufacturers will be rejected

Key Definitions

DHHS Medicaid Drug Rebate Program participant

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

Billing eligibilityOnly products from these participating labelers are eligible to be billed under Medicaid per CMS mandate.

Operational effectNeighborhood will reject retail pharmacy claims for medications from manufacturers not in the DHHS rebate agreement.

Claim rejection for non-rebate manufacturers

Rejection conditionRetail pharmacy claims will be rejected if the medication’s manufacturer has not entered into a drug rebate agreement with DHHS.

Applies toBoth brand-name and generic medications billed to Medicaid.

Provider actionFor brand-name drugs, prescribers should identify and prescribe a comparable alternative from a participating manufacturer.

Pharmacy actionFor generics, dispensing pharmacies should reprocess the claim using the same product from a manufacturer that participates in the rebate agreement.

OpenPayer

Pharmacy Benefit — Medicaid Drug Rebate Program Reminder

Medicaid Drug Rebate Billing Criteria

Product Sourcing and Manufacturer Participation

Actions Required by Prescribers and Pharmacies

Key Definitions