2017 Pharmacy Benefits

Where can I get my prescriptions filled?

 

To locate a pharmacy near you, download the full 2017 Provider and Pharmacy Directory or go to our Member Materials page. If you need additional help finding a pharmacy, please contact Member Services.

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 PerformRx 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 B 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.

Can I use mail-order services to get my drugs?

No. Neighborhood INTEGRITY does not offer mail order services.

Can I continue to get my prescription drugs if they’re not on the List of Covered Drugs (formulary)?

Yes. This is called the continuity of care period. To help you transition, in the first 90 days of coverage you will have access to at least one 30-day supply of Part D drugs and a 90-day supply of other Medicaid-covered drugs you currently take.

Can I get a temporary supply of drugs?

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

  • You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away. We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
  • 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
    • discharge from a hospital to a home, or
    • discharge from a psychiatric hospital with medication regimens

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.

What if a drug on the List of Covered Drugs (formulary) requires Prior Authorization?

Sometimes a drug requires prior authorization. In those cases, your provider must submit medical information to back up the request for the drug before it will be covered. This additional step helps ensure the drug is being used safely and appropriately.

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

For more information call Member Services.

What if Prior Authorization gets denied?

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.

If you or your provider would like to file a coverage determination request for a Part D drug, you can use this form (PDF Document).

What is Step Therapy?

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’s medically necessary to use the originally prescribed medication.

What are specialty drugs?

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 side effects. The pharmacies that provide specialty medications are experienced, knowledgeable and dedicated to the care of our members.

Does Neighborhood cover specialty drugs?

Yes, when your provider makes a special request. If your provider feels you need to take a drug that is not on the formulary, they must request a prior authorization from Neighborhood.

Do I need a prior authorization for a specialty drug?

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.

What is the Medication Therapy Management (MTM) program?

Medication Therapy Management (MTM) 

Neighborhood has partnered with PerformRx to offer medication therapy management programs at no additional cost for members who: 

  • Have multiple medical conditions; 
  • Are taking many prescription drugs; and 
  • Have high drug costs. 

A team of pharmacists and doctors developed these medication therapy programs to help provide better prescription drug coverage for plan members. For example, these programs help us ensure that our members are using the proper drugs to treat their medical conditions and help Neighborhood spot possible medication errors. 

Neighborhood offers medication therapy management programs for members who meet certain criteria. As a Neighborhood member, we may notify you of being enrolled in the program. Neighborhood hopes that you will participate in the program offered to help you manage your medications. Remember, you do not need to pay anything extra to participate. If you are selected as an eligible participant for an MTM program, Neighborhood will send you information about the specific program, including how to disenroll if you choose not to take part.  

If you wish to participate in the program, our pharmacy benefits manager, PerformRx, will be outreaching to you. You will be contacted either via phone by our clinical staff or via direct mail with informational materials. Our outreach to you should take less than 30 minutes to complete. You will be eligible for both the comprehensive medication review, which will be a review of all your medications and therapy programs, and a targeted medication review, which will target your specific conditions. We will provide you an overview of the MTM program, a personal medication list, a medication action plan based on your medications as well as educational information based on the specific conditions which you have. If you opt into this program, we will also be contacting your primary care physician to discuss your current treatments to work to improve your conditions and outcomes. You will be able to receive any information we receive from our consultations with your physicians. 

Every three months, we will send you materials for you to review. We ask that you review this information and provide us any updates so that we are aware of your current information. At your request we will also provide a comprehensive medication review. You may also receive additional information targeted at your specific conditions. These reviews can be helpful in order to review your current drug treatment to ensure that you are receiving the best care. 

To learn more, or to obtain MTM documents, 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 federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users should call 711.

These programs may have limited eligibility criteria and are not considered a benefit; they are available for the following conditions: 

Have at least 3 of the following disease states:

  • Arthritis/rheumatoid arthritis 
  • Chronic heart failure (CHF) 
  • Diabetes 
  • Dyslipidemia 
  • End-stage renal disease (ESRD) 
  • Hypertension 
  • Chronic/disabling mental health conditions 
  • Asthma 
  • Chronic obstructive pulmonary disease (COPD) 
  • Osteoporosis 

Be on at least 5 different medications from the following list to treat those disease states: 

  • ACE inhibitors 
  • Angiotensin II receptor blockers (ARBs) 
  • Antidepressants 
  • Antihyperlipidemics 
  • Antihypertensives 
  • Antipsychotics 
  • Beta blockers 
  • Bisphosphonates 
  • Bronchodilators 
  • Calcium channel blockers 
  • Colony stimulating factors 
  • Disease-modifying anti-rheumatic drugs (DMARDs) 
  • Diuretics 
  • Glucocorticosteroids 
  • Inhaled corticosteroids 
  • Insulins
  • NSAIDs 
  • Oral hypoglycemics 
  • Phosphate binders 
  • Selective serotonin reuptake inhibitors 
  • Vitamin D analogs 

(PDF) MTM Personal Medication List - Blank 

Additional Pharmacy Documents

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

Have questions?

Please call us at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. Neighborhood Health Plan of Rhode Island is a health plan that contracts with both Medicare and Rhode Island Medicaid to provide the benefits of both programs to enrollees. 

This information is available for free in other languages. Please call our Member Services at 1-844-812-6896 (TTY 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. 

Esta información está disponible de forma gratuita en otros idiomas. Por favor llame a nuestro Departamento de Servicios para Miembros al 1-844-812-6896 (TTY 711) de 8 am a 8 pm, lunes-viernes; sábados de 8 am a 12 pm. Los sábados por la tarde, domingos y días festivos federales, se le pedirá que deje un mensaje. Su llamada será devuelta dentro del siguiente día laborable. La llamada es gratuita. 

Estas informações estão disponíveis gratuitamente noutros idiomas. Por favor telefone para os Serviços dos Membros em 1-844-812-6896 (TTY 711), das 8 às 20 horas, de Segunda a Sexta-feira; e das 8 às 12 (meio-dia) aos Sábados. Nos Sábados à tarde, Domingos e feriados federais, poderá ser-lhe pedido que deixe uma mensagem. A sua chamada será respondida no próximo dia útil. Esta chamada é grátis. 

Our plan can also give you materials in Spanish and Portuguese and in formats such as large print, braille, or audio. Call Neighborhood INTEGRITY Member Services to make a standing request to receive your materials now and in the future, in your requested language or alternate format.

Last Updated March 31, 2017, 2:26 pm

H9576_WebPhmBene CMS Approved 9/13/16