2019 Pharmacy Benefits

Where can I get my prescriptions filled?

To locate a pharmacy near you, download the full 2019 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.

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

Yes, Neighborhood INTEGRITY now offers mail order services, which are available through CVS Mail Service Pharmacy. You can now receive convenient delivery of your maintenance medications to the location of your choice. 

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.

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. In the first 90 days of coverage you will have access up to a total of 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 nursing homes will receive 31 days’ supply of Part D drugs and up to a 90-day supply of non-Part D drugs.

Can I get a temporary supply of 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
    • discharge from a hospital to a home, or
    • discharge from a psychiatric hospital with medication regimens
    • 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 effected 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
    • Non-Part D drugs that are not covered by the state of Rhode Island
    • 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.

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.

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, please check our List of Covered Drugs. 

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 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 side effects and drug interactions.

We conduct reviews on members who:

  1. Have a minimum of three multiple chronic conditions
    1.  Chronic conditions that apply: Osteoporosis, Chronic Heart Failure, Diabetes, Depression, Asthma, Chronic Obstructive Pulmonary Disease, or Cardiovascular Disorders
  2. Must be on at least 8 covered chronic/maintenance Part D drugs
  3.  Must have incurred ¼ of the specified annual cost threshold of $4,044 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 and to identify possible medication errors. We attempt to educate members as to drugs currently on the market, making recommendations for lower-cost or generic drugs where applicable.

Once eligible you will receive a welcome letter. 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).  A CMR is a review of member’s medication and medical history and based off this information a pharmacist will offer recommendations. Members can expect pharmacists to assist members with creating a schedule around the best time to take your medications and answering any questions about what they do and possible side effects.

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.

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.

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 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.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 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 holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

ATENCIÓN: Si usted habla inglés, servicios de asistencia con el idioma, de forma gratuita, están disponibles para usted. Llame a Servicios a los Miembros al 1-844-812-6896 (TTY 711), de 8 am a 8 pm, de lunes a viernes, de 8 am a 12 pm los Sábados. En las tardes de los Sábados, domingos y feriados, se le pedirá que deje un mensaje. Su llamada será devuelta dentro del siguiente día hábil. La llamada es gratuita.

ATENÇÃO: Se você fala inglês, o idioma, os serviços de assistência gratuita, estão disponíveis para você. Os serviços de chamada em 1-844-812-6896 TTY (711), 8 am a 8 pm, de segunda a sexta-feira; 8 am a 12 pm no sábado. Nas tardes de sábado, domingos e feriados, você pode ser convidado a deixar uma mensagem. A sua chamada será devolvido no próximo dia útil. A ligação é gratuita.

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. 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 February 11, 2019, 5:06 pm

H9576_WebPhmBene19 Approved 12/6/2018