Latest Neighborhood Health Plan Of Rhode Island prior authorization updates25

• Prior AuthClinical/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.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthReimbursement/Payment PolicyEff. 2026-06-01Durable Medical Equipment (DME) supplies — coverage, prior authorization, frequency and quantity limitsThis document lists coverage, prior authorization requirements, frequency and quantity limits for numerous DME supplies (HCPCS A‑codes and common diabetes/infusion supplies) for members of Neighborhood Health Plan of Rhode Island.Neighborhood Health Plan Of Rhode IslandGeneralAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2026-03-01Empaveli (pegcetacoplan) subcutaneous for C3G and IC-MPGN - Clinical prior authorizationClinical prior authorization policy for subcutaneous Empaveli (pegcetacoplan) for members (Medicaid, Commercial, Medicare) with biopsy‑confirmed Complement 3 glomerulopathy (C3G) or immune-complex membranoproliferative glomerulonephritis (IC-MPGN), including initial and renewal requirements and dosing guidance.Neighborhood Health Plan Of Rhode IslandNephrologyAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/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.Neighborhood Health Plan Of Rhode IslandNephrologyAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/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.Neighborhood Health Plan Of Rhode IslandEndocrinologyAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2026-02-01Delegation and Prior Authorization for Joint/Spine Surgery and Interventional Cardiology ServicesNeighborhood Health Plan Of Rhode IslandOrthopedics/MusculoskeletalAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/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.Neighborhood Health Plan Of Rhode IslandEndocrinologyAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/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.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2026-01-01Drug formulary: ADHD/amphetamines coverage and requirementsPortions of Neighborhood Health Plan of Rhode Island's prescription drug formulary covering ADHD/anti-narcolepsy/amphetamine class medications, tiers, and specific requirements (prior authorization, step therapy, quantity limits) for ACCESS and TRUST plan members effective January 1, 2026.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2026-01-01Formulary — Analgesics and TiersThis document lists covered prescription analgesic drugs, their formulary tiers, and requirements (e.g., prior authorization, step therapy, quantity limits) for Neighborhood Health Plan of Rhode Island members and participating pharmacies.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2026-01-01High-cost multivitamin prior authorization policyDefines prior authorization requirements for multivitamin prescriptions above a $50 per-fill maximum cost edit for Neighborhood Health Plan of Rhode Island Medicaid FIDE SNP members. Affects pharmacy claims adjudication and prescribing providers.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/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.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/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.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthReimbursement/Payment PolicyEff. 2026-01-01Non-Emergent Ambulance Transportation Prior Authorization RequirementRequires prior authorization for certain non-emergent air and ground ambulance services for members enrolled in Neighborhood INTEGRITY for Duals (HMO D-SNP) and Dual CONNECT (HMO D-SNP). Affects providers submitting claims for these members.Neighborhood Health Plan Of Rhode IslandEmergency & Medical TransportationAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Preadmission Screening and Resident Review (PASRR) Requirement for Skilled Nursing Facility RequestsMandates submission of the federally required Preadmission Screening and Resident Review (PASRR) with all new Skilled Nursing Facility (SNF) prior authorization requests to Neighborhood Health Plan of Rhode Island; applies to all new SNF admissions across all lines of business.Neighborhood Health Plan Of Rhode IslandGeneralAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthReimbursement/Payment PolicyEff. 2025-12-01Partial Drug Formulary — Tiers, Prior Authorization, Quantity Limits, and Step TherapyThis document lists prescription drugs, their formulary tiers, and any requirements or limits (e.g., prior authorization, quantity limits, step therapy) applicable to Neighborhood Health Plan of Rhode Island members and participating pharmacies.Neighborhood Health Plan Of Rhode IslandGeneralAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-10-08Diabetes Prevention ProgramDefines coverage, eligibility, provider recognition, exclusions, and billing/prior authorization guidance for the Medicare Diabetes Prevention Program (MDPP) for Neighborhood Health Plan of Rhode Island Medicare Duals (FIDE) and CO-DSNP lines of business. Excludes certain Medicaid and commercial lines.Neighborhood Health Plan Of Rhode IslandEndocrinologyAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-10-01Primary Care Prior Authorization Waiver (Medicaid & Dual Eligible)Implements Rhode Island three-year pilot (Oct 1, 2025–Oct 1, 2028) waiving prior authorization for many medically necessary services ordered by credentialed primary care providers for Medicaid and Dual Eligible members; Medicare benefits excluded.Neighborhood Health Plan Of Rhode IslandPreventive Services & ScreeningAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthAdministrative/Operational PolicyEff. 2025-10-01Primary Care Prior Authorization Waiver for Commercial Lines of BusinessDefines Neighborhood Health Plan of Rhode Island's implementation of Rhode Island legislation (H5120A / R.I. Gen. Laws §27-18.9-2) that prohibits prior authorization for most medically necessary services ordered by credentialed primary care providers for commercial lines of business; affects in-network PCPs and claims processing for Commercial LOB.Neighborhood Health Plan Of Rhode IslandGeneralAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-10-01Prior authorization for non-emergent Joint/Spine surgery and Interventional CardiologyNeighborhood Health Plan Of Rhode IslandOrthopedics/MusculoskeletalAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-10-01Prior authorization for non-emergent joint/spine surgery and interventional cardiologyThis notice informs providers that, for Neighborhood Health Plan of Rhode Island members, Evolent will manage prior authorization for specified non-emergent joint/spine surgeries (Medicaid and Medicare lines) and non-emergent interventional cardiology for adults 19+; Commercial line is excluded. Providers must obtain authorization via Evolent beginning Jan 1, 2026 (requests accepted) with authorizations required for dates of service on or after Feb 1, 2026.Neighborhood Health Plan Of Rhode IslandOrthopedics/MusculoskeletalAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-08-21Delegation of Joint/Spine Surgery and Interventional Cardiology Services to EvolentNeighborhood Health Plan of Rhode Island delegates medical management (prior authorization) for specified non-emergent joint/spine surgeries and interventional cardiology services for Medicaid and Medicare members to Evolent; Commercial line is not included.Neighborhood Health Plan Of Rhode IslandOrthopedics/MusculoskeletalAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-08-12Crenessity (crinecerfont) — Coverage Criteria for Classic Congenital Adrenal HyperplasiaPolicy governing coverage and prior authorization requirements for Crenessity as adjunctive therapy to glucocorticoid replacement in adults and pediatric patients (≥4 years) with classic congenital adrenal hyperplasia (CAH) for Neighborhood Health Plan of Rhode Island (Medicaid scope).Neighborhood Health Plan Of Rhode IslandEndocrinologyAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-08-01Crenessity (crinecerfont) — Classic Congenital Adrenal Hyperplasia (CAH) coverage criteriaPolicy governs prior authorization, dosing, quantity limits, and clinical criteria for Crenessity as adjunctive therapy to glucocorticoid replacement in pediatric (≥4 years) and adult patients with classic 21‑hydroxylase congenital adrenal hyperplasia (CAH). It affects prescribers, pharmacies, and prior authorization reviewers.Neighborhood Health Plan Of Rhode IslandEndocrinologyAll Neighborhood Health Plan of Rhode Island updates
• Prior AuthClinical/Medical PolicyEff. 2025-08-01Journavx (suzetrigine) — Coverage CriteriaThis policy governs prior authorization and coverage criteria for the prescription drug Journavx (suzetrigine) for members of Neighborhood Health Plan of Rhode Island aged 18 and older.Neighborhood Health Plan Of Rhode IslandPharmacy & Specialty DrugsAll Neighborhood Health Plan of Rhode Island updates