2024 Pharmacy Benefits

To locate a pharmacy near you, download the full 2024 Provider and Pharmacy Directory on our Member Materials page. Our pharmacy network may change at any time, but you will get a notice if you are impacted. If you are having trouble and need more help finding a pharmacy, please call Member Services at 1-844-812-6896 (TTY 711).

Always show your member ID card at your network pharmacy when you fill a prescription

The network pharmacy will bill Neighborhood for the cost of your covered prescription drug. If you do not have your member ID card with you when you fill your prescription, ask the pharmacy to call CVS Caremark® to get the the information the pharmacy needs.

If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. If you cannot pay for the drug, contact Member Services right away.

To learn how to ask us to pay you back, see Chapter 7, Section A of the Member Handbook, which can be found on our Member Materials page.

If you need help getting a prescription filled, you can contact Member Services or your care manager.

Yes, Neighborhood INTEGRITY offers mail order services, which are available through CVS Caremark Mail Order Service Pharmacy. You can now receive convenient delivery of your maintenance medications to the location of your choice. Maintenance medications are drugs that you take on a regular basis, for a chronic or long-term medical condition.

You can apply here to enroll in mail service.

Your provider can request a mail service order on your behalf by submitting this form.

For more information, call Member Services.

Yes. If you are a new member in the first 90 days of coverage, you will have access to a 30-day supply of a non-covered Part D drug and will be notified to speak to your provider on how to get your drug covered or switched. This is called a transition fill. New members who live in a Nursing Home can receive up to a 31-day supply of non-covered Part D drug. New members are also eligible to receive up to a 90-day supply of a non-covered non-Part D drug. Renewing members can also get a transition fill within the first 90 days of the new plan year if your drug was removed from our formulary or is now restricted in some way from last year.

Yes. A temporary supply of medication is allowed in the following situations:

• Nursing home residents can get an emergency supply of at least 31 days (or a specific prescribed amount) for a transition-eligible drug while an exception or prior authorization request is being processed. This can be done whether or not you are within a transition period.
• Current members who are having a level-of-care change from one treatment setting to another may qualify for a refill of a drug not on the List of Covered Drugs (formulary). This is done to give the prescriber time to find a new drug on the list or to file an exception. Some examples of level-of-care transitions are:
  • You enter a long-term care (LTC) facility from a hospital or other setting
  • You leave a LTC facility and return to the community
  • You have changed from another plan within Neighborhood or from a different insurer.
  • You have switched from another plan in the middle of the year.
  • If a medication has been affected by a formulary change which causes restrictions.

Transition fills are not allowed in the following situations:

• Prior authorization requirements designed to determine Part A or Part B versus Part D coverage
• Prior authorization requirements designed to ensure you are using a Part D drug for a medically accepted indication
• Medications excluded from coverage
• Prior authorization requirements or other UM rejections designed to promote safe use of a drug

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. You can either change to another drug or request an exception.

To ask for a temporary supply of a drug, call Member Services at 1-844-812-6896 (TTY 711).

Sometimes a drug requires prior authorization (also known as a coverage determination). In those cases, your provider must submit medical information to explain the need for the drug before it will be covered. This additional step helps ensure the drug is being used safely and appropriately.

Tell your provider if your drug requires prior authorization.  Your provider should contact us to get the drug covered for you by submitting this form.

For more information call Member Services at 1-844-812-6896 (TTY 711).

If your provider’s request for prior authorization is denied, Neighborhood will send you and your provider a letter informing you why it was denied and how to appeal the decision, if necessary. For more information on appeals, visit the Grievances and Appeals page.

Step Therapy is a process where certain prescription drugs must be tried before the originally prescribed medication will be covered. Your provider can request an exception if it is medically necessary to use the originally prescribed medication.

Specialty drugs are medications prescribed to treat complex chronic or long-term conditions such as cancer, HIV/AIDS, hepatitis C, multiple sclerosis and others. These conditions usually have few or no alternative therapies. Specialty drugs are complex medications that you can’t always find at your local retail pharmacy.

People who take specialty drugs need extra support to lower health risks and potentially serious medication side effects. The pharmacies that provide specialty medications are experienced, knowledgeable and dedicated to the care of our members.

Yes, please check our List of Covered Drugs to see which drugs are covered.

In most cases, yes. After reviewing your information, your provider can help you get a prior authorization for specialty drugs. Providers need to fax all prior authorization forms to 1-855-829-2875.

After the specialty drug is approved, your provider will be informed about the options for specialty drugs, including Neighborhood INTEGRITY specialty vendors or pharmacies where you can get the drugs.

Neighborhood Health Plan of Rhode Island offers a Medication Therapy Management (MTM) program free to our members. The goal of our MTM program is to ensure you are receiving the most effective medications, while also helping to reduce the risk of medication side effects and drug interactions.

The following members are eligible for  the MTM Program:

1. Those identified by the Drug Management Program as having a high risk for dependence and/or abuse

OR

2. Those who have at least three chronic conditions

Chronic conditions that apply include: Chronic Heart Failure, Diabetes, High Cholesterol (Dyslipidemia), High Blood Pressure (Hypertension), Asthma, Chronic Obstructive Pulmonary Disease (COPD), Chronic Alcohol and Other Drug Dependence, or HIV/AIDS
AND

Is on 8 or more covered chronic/maintenance Part D drugs
AND

Has met one-fourth of the annual cost threshold of $5,330 in the last three months.

Neighborhood uses the MTM Program to help make sure our members are taking the right drugs to treat their medical conditions, to look for possible medication errors, to reduce the risk of adverse events, and to improve medication adherence. We provide education to members about available medications on the market and make recommendations for lower-cost or generic drugs where applicable.  The MTM Program has two types of medication reviews: a Comprehensive Medication Review and a Targeted Medication Review.

Every year, members who qualify for the MTM Program are offered a Comprehensive Medication Review (CMR). A CMR is a review of the member’s medications and medical history. Based on this information, a health care provider then offers recommendations meant to teach members more about their prescriptions, over the counter products, herbal therapies and dietary supplements. Health care providers will also assist members with creating a schedule for the best time to take medications, and answer questions about what the medications do and any possible side effects.

If a member is eligible, they will receive a welcome letter from Neighborhood.

Members may also get a call to set up time for a one-on-one medication review. This can be done by phone, telehealth or in a face-to-face meeting. People involved in the review may include the member, the provider who prescribed the drug, a caregiver, the pharmacy/pharmacist, a healthcare proxy or a legal guardian. The review can be done by or at a local pharmacy or by contacting the Pharmacy Department here at Neighborhood.

After receiving the welcome letter, members will then set up an appointment to go over a Comprehensive Medication Review (CMR). The CMR usually takes less than 30 minutes to complete.  After the CMR, members are given an individualized written summary (via Mail, Fax, Email, Web Portal Access, or In Person Delivery) including a cover letter, medication action plan, and personal medication list.

Quarterly, Neighborhood will perform Targeted Medication Reviews (TMR) for the member. A TMR looks at specific medication-related problems or identifies new drug therapy problems. The results of the TMR will be talked about either in a face-to-face meeting, over the phone or by mail with the member, their provider, caregiver or legal guardian.

For information about the MTM Program or information on how to get MTM documents, including the medication list, please call Member Services at 1-844-812-6896 (TTY 711).

Some medications, when administered at the Provider’s office need additional review (Organization Determination or prior authorization) before being administered. To obtain an organization determination for a medication on the Medical Benefit, requests can be received by:

Fax: 1-844-639-7906

Phone: 1-844-812-6896 (TTY 711)

Electronically: https://www.nhpri.org/pharmacy-general-medical-authorization-eform/  OR

Mail: **Attention Pharmacy Department**, 910 Douglas Pike, Smithfield, RI 02917

For questions regarding the process or status of a Pharmacy Medical Benefit Request, please call 1-844-812-6896 (TTY 711).

Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications at home for some medications, or through a local safe disposal program.

Locating a community safe drug disposal site

A drug take-back site is the best way to safely dispose of medications. To find drug take back sites near you, visit the website below and enter your location:

https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e2s1

Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe drug disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.

Mailing medications to drug disposal sites

Medications may be mailed to authorized sites using approved packages. Information on mail-back sites can be found at www.deatakeback.com.

Safe at-home medication disposal

You can safely dispose of many medications through the trash or by flushing them down the toilet. Visit the following website to learn more about safe at-home disposal:

https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html

• Follow these steps for medication disposal in the trash: Remove medication labels to protect your personal information
• Mix medications with undesirable substances, such as dirt or used coffee grounds
• Place mixture in a sealed container, such as an empty margarine tub

To learn more, or to obtain informational materials about MTM, please call Member Services at 1-844-812-6896 from 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays, and holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users should call 711.

Vaccines

Neighborhood INTEGRITY covers all FDA-approved COVID-19 vaccinations. As new booster shots become available, Neighborhood will work to get these covered at the pharmacy as soon as possible.

Oral antivirals

Neighborhood INTEGRITY provides coverage of FDA-approved oral COVID-19 treatments with a prescription from your provider. Please check the most recent drug list for specific coverage information or call member services for more information.

Tests

Neighborhood INTEGRITY covers COVID-19 tests as part of the Medicaid portion of the Neighborhood INTEGRITY benefit. We will cover COVID-19 tests at the pharmacy with a prescription from your provider.

The documents listed below can give you more specific information on your pharmacy benefit:

• Searchable List of Covered Drugs
• Request for Medicare Prescription Drug Coverage Determination or Exception
• Request for Medicare Prescription Drug Redetermination
• Member Reimbursement Form for Part D Drugs
• Submit Medicare Prescription Drug Coverage Determination Online
• Submit Medicare Prescription Drug Redetermination Online
• Pharmacy Transition Fill Policy
• Step Therapy Criteria
• Prior Authorization List
• Medicare Part B Medications Requiring Step Therapy
• List of Durable Medical Equipment Available at a Pharmacy  English    Spanish    Portuguese   Khmer
• INTEGRITY (MMP) Formulary Changes December 2024
• Appointment Of Representative (AOR) Form English     Spanish     Portuguese     Khmer
• Drug Takeback Flier English    Spanish    Portuguese     Khmer