Neighborhood Health Plan Of Rhode Island Coverage Criteria
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Latest Neighborhood Health Plan Of Rhode Island coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Brivaracetam (Briviact) coverage criteria for partial-onset seizuresCriteria for initial approval, continuation, quantity limits, and coverage duration for brivaracetam (Briviact) for members (Medicaid scope) beginning 2026-07-01.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Compounded Drug ProductsDefines prior authorization documentation requirements, clinical coverage criteria, continuation criteria, exclusions, and maximum coverage duration for compounded drug products under Neighborhood Health Plan of Rhode Island.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Slynd (drospirenone) 4 mg tablet — Coverage CriteriaCovers authorization and coverage criteria for Slynd (drospirenone) 4 mg tablets as a contraceptive for members of Neighborhood Health Plan of Rhode Island under the pharmacy benefit.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Jascayd (nerandomilast) — Coverage Criteria for Idiopathic Pulmonary Fibrosis (IPF) and Progressive Pulmonary Fibrosis (PPF)Covers medical necessity criteria and authorization requirements for Jascayd (nerandomilast) for treatment of idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) in adults for Neighborhood Health Plan of Rhode Island members.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Palsonify (paltusotine) — Coverage Criteria for AcromegalyCovers medical necessity and authorization criteria for Palsonify (paltusotine) tablets for treatment of adults with acromegaly, including initial and continuation authorization and quantity limits; applies to Medicaid members of Neighborhood Health Plan of Rhode Island.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Redemplo (plozasiran) — Coverage Criteria for Familial Chylomicronemia SyndromeDefines coverage and medical necessity criteria for Redemplo (plozasiran) as adjunct therapy to reduce triglycerides in adults with familial chylomicronemia syndrome (FCS); applies to requests for initial and continued authorization.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Voyxact (sibeprenlimab) — Coverage Criteria for Primary IgA NephropathyCovers criteria for authorization and continuation of Voyxact for adults with primary immunoglobulin A nephropathy (IgAN) at risk for progression, including required clinical and lab documentation and quantity limits.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Empaveli (pegcetacoplan) — Non-Oncology Coverage Criteria (Subcutaneous)Prior authorization and coverage criteria for Empaveli (pegcetacoplan) subcutaneous use to reduce proteinuria in members (≥12 years) with C3G or IC-MPGN; applies to Medicaid, Commercial, and Medicare lines of business.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-11Continuous Glucose Monitoring (CGM)This policy governs prior authorization, coverage criteria, and quantity limits for continuous glucose monitoring systems for Neighborhood Health Plan of Rhode Island members across specified product lines.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Andembry (garadacimab-gxii) for prophylaxis of hereditary angioedema — Coverage CriteriaCovers criteria, dosing, quantity limits, and authorization requirements for Andembry (garadacimab-gxii) when used for prevention of hereditary angioedema (HAE) in members aged 12 and older.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Anzupgo (delgocitinib) cream — coverage criteria for chronic hand eczemaCovers criteria for initiation and continuation of topical Anzupgo for adults with moderate to severe chronic hand eczema, including prescribing provider requirements, exclusions for concomitant therapies, and quantity limits.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Brinsupri for non-cystic fibrosis bronchiectasis — Coverage CriteriaCovers medical necessity criteria, authorization, and quantity limits for Brinsupri (adult and pediatric ≥12 years) to treat non-cystic fibrosis bronchiectasis for Neighborhood Health Plan of Rhode Island Medicaid members.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Ekterly (sebetralstat) — coverage criteria for acute hereditary angioedema (HAE) attacksCovers authorization criteria, continuation, and quantity limits for Ekterly (sebetralstat) tablets to treat acute HAE attacks in patients aged 12 and older when clinical and safety criteria are met.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01PapzimeosPolicy governs coverage, dosing, authorization length, diagnostic eligibility, and billing codes for Papzimeos for Medicaid, Commercial, and Medicare members per Neighborhood Health Plan of Rhode Island.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Sephience (sepiapterin) — coverage criteria for sepiapterin‑responsive PKUCovers use of Sephience (sepiapterin) for treatment of sepiapterin‑responsive phenylketonuria (HPA/PKU) in members aged ≥1 month when approval criteria are met; governs prior authorization, coverage duration, and clinical criteria for Neighborhood Health Plan of Rhode Island members.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Commercial Drug Formulary — Outpatient Pharmacy Coverage CriteriaAll Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Coverage Criteria — High-cost over-the-counter lidocaine patchesPolicy governs prior authorization and coverage criteria for high-cost over-the-counter (OTC) lidocaine patch preparations for Neighborhood Health Plan of Rhode Island members in the Medicaid portion of a FIDE SNP.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Neighborhood Health Plan Formulary (Commercial) — Outpatient Drug Formulary Coverage CriteriaDefines the outpatient drug formulary, coverage rules, prior authorization, step therapy, exceptions, and processes for prescribers, pharmacists, and members under Neighborhood Health Plan of Rhode Island's Commercial pharmacy benefit.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Neighborhood Health Plan of Rhode Island Medicaid Drug Formulary - Outpatient Pharmacy Coverage CriteriaDefines the outpatient pharmacy formulary, coverage rules, prior authorization, step therapy, and exception processes for Neighborhood Health Plan of Rhode Island Medicaid members and guides prescribers, pharmacists, and members on use and appeals.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Non-Emergency Ambulance ServicesDefines medical necessity, coverage criteria, and billing limitations for non-emergency ground and air ambulance transport for Neighborhood Health Plan of Rhode Island members in specified product lines.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase) — Coverage CriteriaCovers medical benefit criteria for Vyvgart Hytrulo subcutaneous formulation for adults with generalized myasthenia gravis (AChR antibody positive) and chronic inflammatory demyelinating polyneuropathy (CIDP), including initial and continuation authorization requirements and quantity limits.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Weight loss medication coverage (Wegovy, Zepbound)Defines medical necessity criteria, dosing limits, and documentation requirements for coverage of Wegovy (semaglutide) and Zepbound (tirzepatide) for members of Neighborhood Health Plan of Rhode Island.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Generic Oncology Drugs Coverage Criteria (Attachment A)All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Alhemo (concizumab-mtci) coverage for hemophilia prophylaxisDefines pharmacy and medical coverage, dosing, authorization, and clinical criteria for Alhemo (concizumab-mtci) for members with hemophilia A or B (with or without inhibitors) aged 12 years and older under Neighborhood Health Plan of Rhode Island Medicaid/Commercial/Medicare where specified.All Neighborhood Health Plan of Rhode Island updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Encelto (revakinagene taroretcel-lwey) (Intravitreal Implant) coverage criteriaDefines coverage, authorization, and clinical criteria for Encelto intravitreal implant for members (Medicaid, Commercial, Medicare) with MacTel type 2; applies to providers and authorized treatment facilities performing implantation.All Neighborhood Health Plan of Rhode Island updates
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Tool Description
Search Neighborhood Health Plan Of Rhode Island coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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