CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid Non‑Formulary Quantity Limits

Defines approved quantity limits and daily limits for non‑formulary medications for Neighborhood Health Plan of Rhode Island Medicaid members; applies to pharmacy benefit management and dispensing pharmacies enforcing quantity limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid Non‑Formulary Quantity Limits

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionEnforce the listed approved quantity and daily limits for non‑formulary medications when dispensing to Medicaid members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks (partial list of drugs shown)

per 28/30 daysquantity-limit time windows

injectables & oralforms covered

Non‑Formulary Quantity Limits — Examples

Sample quantity limit entries

Examples of product-specific limits from the document (partial):

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Sample non-formulary quantity rules

Per-drug quantity limits (non‑formulary) — examples below are excerpts from the list:

RASUVO PEN 12.5MG/0.25ML — Limit: 2 cartridges per 28 days = 4 injections per 28 days; Package/code mapping: 3004405510E110 -> 6625005000D517

REBIF INJ 22/0.5 — Limit: 2 cartridges per 28 days = 12 (6 ml) per 28 days; Package/code mapping: 62403060450520

REDITREX INJ 7.5/.3ML — Limit: 12 (4.2 ml) per 28 days = 4 syringes per 28 days; Package/code mapping: 6240306045E560, 62403060450560 -> 6625005000E508

RETROVIR CAP 100MG — Limit: 12 (4.2 ml) per 28 days = 180 per 30 days; Package/code mapping: 12108085000110

SAXENDA INJ 18MG/3ML — Limit: 12 (4.2 ml) per 28 days = 5 pens per 30 days; Package/code mapping: 61252050000220

VIEKIRA PAK TAB — Limit: 30 per 30 days = pak (112) per 28 days; Package/code mapping: 1235990460B720

VIREAD TAB 300MG — Limit: 30 per 30 days; Package/code mapping: 12108570100320

XARELTO TAB 2.5MG — Limit: 30 per 30 days = 60 per 30 days; Package/code mapping: 83370060000310

ZIAGEN SOL 20MG/ML — Limit: 30 per 30 days = 900 per 30 days; Package/code mapping: 12105005102020

ZTLIDO 1.8% PATCH — Limit: 1 = 90 patches per 30 days; Package/code mapping: 90850060005910

Target GPI and Package/Code Mappings

Example Target GPIsmixed

665007000E520	Target GPI for ACTEMRA INJ 162MG/0.9ML (example)
90350010003720	Target GPI for ACYCLOVIR 5% CREAM (example)

Examples of package/code mappingsNDC

3004405510E110	Package/code mapping shown for RASUVO pen strengths
62403060450520	Package/code mapping shown for REBIF injection

Recurring package/codeNDC

21533070300140

Package/code mapping referenced for multiple products (e.g., TRACLEER, TALTZ, others)

inv-06: Cosentyx

Strength & form150 mg (1 ml) — injection

Approved quantity150 mg (1 ml) per 28 days

Daily limit0.04 (quantity per day)

inv-07: Bryhali lot annual

ProductBRYHALI LOT 0.01%

Approved quantity400 gm per 365 days

Daily limitnla (not listed/available)

inv-08: Example per-28-day syringe limit

Example calculation (per-28-day syringe limit)12 units (4.2 ml) per 28 days = 4 syringes per 28 days

Daily limit (derived)0.15 (quantity per day) — listed for REDITREX strengths

Typical unit translationunits (ml) converted to syringe count for dispensing

inv-09: Example tablet caps per 30 days

Example productSUSTIVA caps (200 mg shown as example)

Approved quantity (tablet/capsule)90 per 30 days

Derived daily limit3 (quantity per day) — shown for SUSTIVA caps

What Providers and Pharmacies Must Do

Billing Rule

Quantity limits listing (partial)

This section lists approved quantity and daily limits for specific non‑formulary medications. The policy provides per‑product approved quantity (for example, per 14 or 28 days) and corresponding daily limits (quantity per day), and includes target GPI codes where available. Examples from the listing: ACTEMRA INJ 162MG/0.9ML — Approved Quantity = 162 mg per week; Daily Limit = 0.13. ACTEMRA formulations (40 mg, 80 mg, autoinjectors) show approved ml or autoinjector counts per 14 or 28 days and corresponding daily limits. AFINITOR TAB 10MG — Approved Quantity = 30 per 30 days. ACYCLOVIR 5% CREAM — Approved Quantity = 5 gm per 30 days. These quantity and daily‑limit entries must be observed when prescribing and dispensing non‑formulary products to avoid denials or claim edits.

Approved Quantity and Daily Limit are provided per product (e.g., per 14 days, per 28 days, per 30 days, per week).
Target GPI or equivalent product identifier is included when available and should be used for claims mapping.
Examples: ACTEMRA INJ 162MG/0.9ML — Approved Quantity = 162 mg per week; Daily Limit = 0.13.
Examples: ACTEMRA INJ 40MG/2.0ML and 80MG/1.0ML — Approved Quantity = 40 ml per 14 days; Daily Limit = 2.86 (or 40 ml (10 vials) per 14 days for some presentations).
AFINITOR TAB 10MG — Approved Quantity = 30 per 30 days; Daily Limit shown.
ACYCLOVIR 5% CREAM — Approved Quantity = 5 gm per 30 days; Daily Limit noted as NLA where applicable.

Billing Rule

Quantity limits and package mappings

The listing also maps package sizes / cartridge counts and package codes to per‑drug quantity limits for dispensing and claims processing. Examples include RASUVO pen presentations where cartridges per 28 days are specified (commonly 2 cartridges per 28 days = 4 injections per 28 days) and the equivalent daily quantity (a decimal daily limit) plus a target package code/GPI mapping to support claim adjudication. Pharmacies must dispense within the approved package/quantity mapping and bill using the mapped GPI/NDC or package code to ensure proper processing.

Per‑product package mapping is provided (e.g., cartridges per 28 days with equivalent injections per period).
A decimal daily limit is supplied for each mapped package size to support claims edits (e.g., 0.0720 = 0.036 etc. as shown for RASUVO variants).
Target GPI or package code (where listed) must be used on claims to align the dispensed package with the policy quantity limit (examples: RASUVO pen codes mapped to 3004405510E110 = 6625005000D5xx).
Dispense and billing must match the approved package count (e.g., 2 cartridges per 28 days) — deviations may trigger claim denials or requests for prior authorization.

Key Terms and Calculation Notes

inv-12: Approved Quantity

DefinitionApproved Quantity = the maximum quantity allowed for the product over the specified time period (e.g., per 28 days, per 30 days).

Example unitsMay be expressed in mg, ml, tablets, capsules, cartridges, syringes, or grams.

PurposeUsed to enforce dispensing limits for non‑formulary medications under the Medicaid pharmacy benefit.

inv-13: Daily Limit

DefinitionDaily Limit = the allowable average daily amount derived from the approved quantity and the specified time window.

CalculationDaily limit = (approved quantity) ÷ (days in time window). Example: 150 mg per 28 days → 0.04 (quantity per day).

UseDisplayed alongside approved quantity to guide average daily dispensing and claims adjudication.

inv-14: Quantity limit

PresentationQuantity limits are shown as counts per 28- or 30-day windows (or per 365 days) and translated into common units where applicable.

ExamplesPer-28-day: 12 units (4.2 ml) = 4 syringes per 28 days; Per-30-day: 90 capsules per 30 days.

Typical translationsCartridges → injections, ml → syringe counts, per-period counts → daily averages for adjudication.