RIte Care Pharmacy Benefit (Generics)
To search the complete Formulary for RIte Care (Group Number 1100), click HERE. Policies Related to the Formulary for RIte Care
To view the general criteria for approval of brand-name drug coverage for RIte Care members, click HERE.
Drug Benefit Exception (Prior Authorization) Forms for the RIte Care Pharmacy Benefit
Advair/Symbicort
Aldara Angiotensin Receptor Blockers Anorexiant Anti HSV Agents
Antihistamines Baraclude Botox
[Provider office must buy the drug and bill Neighborhood] Byetta
Cerebral Stimulants
Chantix Cimzia Copegus Cozaar Elidel-Protopic Emend Enbrel Epi Pen Epoetin (Chemo Induced) Epoetin (Non-Chemo Induced) Fluoroquinolones Growth Hormone (Omnitrope) Humira Hyaluronate Products (ex. Synvisc, Hyalgan) Infergen
Inhalation Assist Device Insulin Pen Intron-A Invega Sustenna
Lamisil Lupron Lyrica Nutritional Supplement (ex. Boost, Ensure)
[Do not submit form if the patient is under 5 years old or pregnant or breast feeding; refer patient to WIC for coverage of Nutritional Supplement] Orencia
Oxycontin Pantoprazole Paroxetine Peg-Intron Pegasys
Propoxyphene containing products Proton Pump Inhibitors Proton Pump Inhibitor - Plavix Interaction Protopic
Provigil Rebetol Remicade Restasis Retin A Risperdal Consta
Roferon-A
Sedative Hypnotics
Singulair (Covered only for asthma) SNRIs Sporanox Statins Stimulants
Suboxone Subutex SSRIs Symlin
Thiazolidinedione (TZD)
Triptans Tysabri Ventavis Weight Loss (Alli, Phentermine) Xolair Zyprexa Relprevv Zyvox All Others
RIte Care Pharmacy Benefits changed February 1, 2009 Beginning February 1, 2009, the pharmacy benefit for RIte Care members requires use of generic drugs prior to covering most brand name drugs. Many brand name drugs previously included in Neighborhood’s formulary are now only available after Prior Authorization. Please ensure that your patients’ prescriptions comply with the Formulary for RIte Care (Group Number 1100). This policy applies only to members in the general RIte Care population. This policy does NOT apply to: Children with Special Health Care Needs Children in Substitute Care Rhody Health Partners for Adults with Disabilities, Medicaid-only
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