CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pharmacy Benefit Medicaid Drug Rebate Program (MDRP)

Governance of which outpatient pharmacy drugs may be billed under Neighborhood Health Plan of Rhode Island's Medicaid benefit—affects retail pharmacies dispensing to Neighborhood Medicaid members. Does not apply to Neighborhood's Commercial or INTEGRITY plans.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit Medicaid Drug Rebate Program (MDRP)

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateJanuary 2024

Next Review DateN/A

Key ActionRetail pharmacy claims will be rejected if the medication is produced by a manufacturer not participating in the DHHS Medicaid Drug Rebate Program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1policy applies to Medicaid benefit only

bothmedication types affected

rejectedclaims for nonparticipating manufacturers

Medicaid Billing Eligibility

Medicaid billing eligibility criteria

Covered when ALL of the following are met:

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

Applies to both brand-name and generic products dispensed to Neighborhood Medicaid members (does not apply to Neighborhood Commercial or INTEGRITY plans).

If the medication is produced by a manufacturer not participating in the DHHS rebate agreement, the retail pharmacy claim will be rejected.

For brand-name prescriptions, prescribers should identify and prescribe a comparable alternative from a participating labeler; for generic prescriptions, the dispensing pharmacy should reprocess the claim using the same product from a participating manufacturer.

Manufacturer Participation & Code Reference

Rebate-participating manufacturersmixed

No codes listed

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPharmacy Benefit Medicaid Drug Rebate Program (MDRP)

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateJanuary 2024

Next Review DateN/A

Key ActionRetail pharmacy claims will be rejected if the medication is produced by a manufacturer not participating in the DHHS Medicaid Drug Rebate Program.

SourceLink

On This Page

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.

Manufacturer participation requirement

RequirementOnly drugs manufactured or distributed by labelers participating in a DHHS drug rebate agreement are eligible to be billed under Medicaid.

ScopeApplies to both brand-name and generic medications dispensed to Neighborhood Medicaid members.

Claim consequenceNeighborhood will reject retail pharmacy claims for medications produced by manufacturers not participating in the DHHS rebate agreement.

Remediation — brand-namePrescribers should identify and prescribe a comparable alternative from a participating labeler when the prescribed product is brand-name.

Remediation — genericDispensing pharmacies should reprocess the claim using the same product from a manufacturer that participates in the rebate agreement for generic prescriptions.

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

Billing Requirements and Remediation

Denial Risk

Medicaid Drug Rebate Program billing requirement

Neighborhood will reject retail pharmacy claims for medications produced by manufacturers who have not entered into a drug rebate agreement with the U.S. Department of Health and Human Services (DHHS). This requirement applies to both brand-name and generic medications and only affects Neighborhood Medicaid—does not apply to Commercial or INTEGRITY plans.

Applies to both brand-name and generic products.
Does not apply to Neighborhood Commercial or INTEGRITY plans.

Billing Rule

Provider and pharmacy remediation steps for non‑participating labelers

When a prescribed product is from a non-participating labeler: prescribers must identify and prescribe a comparable alternative for brand‑name medications; dispensing pharmacies must reprocess the claim using the same generic product from a manufacturer that participates in the DHHS rebate agreement.

For brand‑name prescriptions: prescriber to identify and prescribe a comparable alternative for the member.
For generic prescriptions: dispensing pharmacy should reprocess the claim using the same product from a participating manufacturer.

Program Definitions

Medicaid Drug Rebate Program (MDRP) / rebate agreement

DefinitionMedicaid Drug Rebate Program (MDRP): a DHHS drug rebate agreement required by the Centers for Medicare & Medicaid Services under which only drugs from participating labelers are billable to Medicaid.

PurposeEnsures Medicaid claims are billed only for drugs from manufacturers who have entered into a drug rebate agreement with the United States Department of Health and Human Services.

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

ApplicabilityMandated by CMS and applies to Neighborhood's Medicaid benefit (not applicable to Commercial or INTEGRITY plans).