2022 Pharmacy Benefits

To locate a pharmacy near you, download the full 2022 Provider and Pharmacy Directory or go to our Member Materials page. If you need additional help finding a pharmacy, please contact Member Services. The pharmacy network may change at any time. You will receive a notice when necessary.

Show your member ID card when you fill a prescription

Show your member ID card at your network pharmacy. The network pharmacy will bill the plan for the cost of the 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 necessary information.

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.

This is called the continuity of care period. In the first 90 days of coverage, you will have access to up to a total of a 30 days’ supply of a non-covered drug and will be notified to speak to your physician on how to get your drug covered or switched. Members who are in a Nursing Home can receive up to a 31 days’ supply of Part D drugs. Members are also eligible to receive up to a 90-day supply of non-Part D drugs.

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

• Nursing home residents are allowed an emergency supply of at least 31 days or prescribed quantity for transition-eligible drugs while an exception or prior authorization request is being processed, regardless of whether they are within their transition period.
• You are a current member and experiencing a level-of-care change from one treatment setting to another. You may qualify for a refill of a drug not on the List of Covered Drugs (formulary) to give your doctor or prescriber time to locate one on the list or file an exception.  Some examples of level-of-care transitions are:
  • enter a long-term care (LTC) facility from a hospital or other setting
  • 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.
• Even in situations described above, transition fills are not allowed in the following circumstances:
  • Prior authorization requirements designed to determine Part A or Part B versus Part D coverage
  • Medications excluded from coverage
  • Prior authorization requirements or other UM rejections designed to promote safe use of a drug

To ask for a temporary supply of a drug, call Member Services.

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.

Sometimes a drug requires prior authorization. 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.

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.

In most cases, yes. Authorizations are based on medical need, which is determined by the drug policy, evidence-based medicine, benefits, regulations, contracts and medical judgment.

Your provider may obtain prior authorization for specialty drugs by faxing a prior authorization form to 1-855-829-2875.

Once we have prior authorization and 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.

Medication Therapy Management (MTM)

Neighborhood Health Plan of Rhode Island offers the 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.

We conduct reviews on members who meet one of the following:

1. Are identified by the Drug Management Program as having a high risk for dependence and/or abuse OR
2. A) Have a minimum of three multiple chronic conditions
   Chronic conditions that apply: 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
3. B) Must be on at least 8 covered chronic/maintenance Part D drugs   AND
4. C) Must have incurred ¼ of the specified annual cost threshold of $4,696 in the previous three months

We use the MTM program to help make sure our members are using appropriate drugs to treat their medical conditions, to identify 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 consists of two types of medication reviews, a Comprehensive Medication Review and a Targeted Medication Review.

On at least a yearly basis you will be offered a Comprehensive Medication Review (CMR). A CMR is a review of your medication and medical history and based off this information a health care provider will offer recommendations designed to increase your knowledge of your prescriptions, over the counter products, herbal therapies and dietary supplements. Members can expect health care providers to assist members with creating a schedule around the best time to take medications and answering any questions about what they do and possible side effects.

Once eligible you will receive a welcome letter. You may also receive a call to set up your one-on-one medication review. MTM can be conducted via phone, telehealth or face-to-face and the recipient of the intervention can be the member, prescriber, caregiver, pharmacy/pharmacist, healthcare proxy or legal guardian. This can be done by or at your local pharmacy or you can contact 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), which should take less than 30 minutes to complete.  After the consultation, members will be provided (via Mail, Fax, Email, Web Portal Access, or In-Person Delivery) an individualized written summary including a cover letter, medication action plan, and personal medication list.

On at least a quarterly basis, Neighborhood INTEGRITY will perform Targeted Medication Reviews (TMR). A TMR looks at specific medication-related problems or identifies new drug therapy problems which will be discussed face to face, over the phone or by mail with you, your provider, caregiver or legal guardian.

For information about how to obtain MTM documents, including the medication list, please call 1-844-812-6896 (TTY 711).

The Neighborhood Health Plan of Rhode Island MTM Program is dedicated to providing you with information about safe medication disposal. 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 through a local safe disposal program or at home for some medications.

• 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 disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.

• Mailing medications to accepting 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.