2026 Pharmacy Benefits

The List of Covered Drugs (LOCD) – also known as the formulary – is a list of prescription medications that are covered by the Neighborhood Dual CONNECT health plan. The LOCD includes both generic and name-brand medications.

To find out if your medication is covered by Neighborhood Dual CONNECT, search the List of Covered Drugs.

Yes. The List of Covered Drugs (LOCD) can change from time to time. In most cases, you will receive notice from us before a change is made. For more information, please refer to your Member Handbook.

Dual CONNECT Formulary Changes (COMING SOON)

Yes. If you are a new member who has been with Neighborhood for less than 90 days, you can get a 30-day supply of a non-covered Part D drug. After this time, you will need to talk to your provider about how to get your drug covered or get your prescription switched to a new drug. 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.

Renewing Dual CONNECT members can also get a transition fill within the first 90 days of a new plan year if their drug was removed from the Neighborhood formulary or has been restricted in some way from the previous year.

Click here to read Neighborhood’s Pharmacy Transition Fill Policy.

If the above scenarios do not apply, you can ask our plan to make an exception for your drugs not on the LOCD. Please see the Prior Authorization section below for more information.

You can find a pharmacy near you, by searching the Dual CONNECT 2026 Provider and Pharmacy Directory or by calling Member Services at 1-844-812-6896 (TTY 711). You can also search for a network pharmacy using our searchable pharmacy directory¹.

Always show your member ID card at the 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 information the pharmacy needs.

If for some reason the pharmacy cannot get the information they need, you may have to pay the full cost of the prescription when you pick it up. If you cannot pay for the drug or need help getting a prescription filled, call Member Services right away.

To learn how to ask us to pay you back, see Chapter 7, Section 2 of the Evidence of Coverage, which can be found on our Member Materials page.

¹Neighborhood’s pharmacy network may change at any time. You will get a notice if a change in the network affects you.

Yes. Neighborhood offers mail order services through CVS Caremark Mail Order Service Pharmacy. As an Dual CONNECT member, you can get maintenance medications² delivered to the location of your choice.

• Click here to enroll in mail service or
• Ask your provider to request a mail service order for you by submitting this form in English, Spanish, or Portuguese (COMING SOON).

For more information on pharmacy mail order services, call Member Services at 1-844-812-6896 (TTY 711).

²Maintenance medications are drugs that you take on a regular basis, for a chronic or long-term medical condition.

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

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). Sometimes a drug is not on our List of Covered Drugs and requires authorization (also known as an exception). 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 make sure the drug is being used safely and appropriately.

Tell your provider if your drug requires prior authorization or is not covered.  You or your provider will need to contact Neighborhood to get the drug covered for you by submitting a request:

• By fax: 1-855-829-2875
• By phone: 1-844-812-6896 (TTY 711)
• Electronically via CoverMyMeds  OR
• By mail: CVS Caremark Part D Appeals and Exceptions PO BOX 52000, MC109 Phoenix, AZ 85072-2000

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

Click here to view Neighborhood’s Prior Authorization List.

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

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 this type of Part B medication, send your request:

• By fax: 1-844-639-7906
• By phone: 1-844-812-6896 (TTY 711)
• Electronically at https://www.nhpri.org/pharmacy-general-medical-authorization-eform/ OR
• By mail to Neighborhood Health Plan of Rhode Island, Attention Pharmacy Department, 910 Douglas Pike, Smithfield, RI 02917

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

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.

Click to review Neighborhood’s Medicare Part B Step Therapy Policy (for drugs administered by your provider in their office) or Neighborhood’s Medicare Part D Step Therapy Criteria (for drugs you get at the pharmacy).

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 by submitting a request:

• By fax: 1-855-829-2875
• By phone: 1-844-812-6896 (TTY 711)
• Electronically via CoverMyMeds OR
• By mail: CVS Caremark Part D Appeals and Exceptions PO BOX 52000, MC109 Phoenix, AZ 85072-2000

The Neighborhood Dual CONNECT Medication Therapy Management (MTM) Program is all about you and your health. The MTM Program helps members like you get the most out of your medications by:

• Preventing or reducing drug-related risks
• Supporting good lifestyle habits
• Providing information for safe medication disposal options

Members can be enrolled in the Neighborhood Dual CONNECT MTM Program if you³:

1. Have coverage limitation(s) in place for medication(s) with a high risk for dependence and/or abuse, or
2. Meet the following criteria:

• You have three or more of these conditions:
  • Alzheimer’s disease
  • Bone disease – arthritis (osteoarthritis, osteoporosis, rheumatoid arthritis)
  • Chronic congestive heart failure
  • Diabetes
  • Dyslipidemia
  • End-stage renal disease
  • HIV/AIDS
  • Hypertension
  • Mental health (depression, schizophrenia, bipolar disorder, chronic/disabling mental health conditions)
  • Respiratory disease (asthma, COPD, chronic lung disorders)
• You take eight or more routine medications covered by your plan
• You are likely to spend more than $1,276 in Part D prescription drug costs in 2026

³Member participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to members for the MTM Program.

Neighborhood will mail you a letter if you qualify for the MTM Program. You may also receive a call to set up your one-on-one medication review.

In the MTM Program, you will receive the following services from a health care provider:

• Comprehensive medication review
• Targeted medication review

The comprehensive medication review is completed with a health care provider in person or over the phone. During the review you will discuss all of the medications you are taking including your prescriptions, over-the-counter (OTC) drugs, herbal therapies, and dietary supplements.

This review usually takes 20 minutes or less to complete. During the review, you can ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications. If more information is needed, the health care provider may contact your prescriber.

After your review, you will receive a summary of what was discussed. The summary will include:

• Recommended To-Do List. Your to-do list may include suggestions for you and your prescriber to discuss during your next visit.
• Medication List. This is a list of all the medications discussed during your review. You can keep this list and share it with your prescribers and/or caregivers.

Click for a blank copy of the Medication List in English or Spanish, or Portuguese (COMING SOON) to use to track your medications.

For the comprehensive medication review, you may get a call from:

• A pharmacy where you recently filled one or more of your prescriptions. You can choose to complete the review with the pharmacist in person or over the phone.
• A health care provider may also call to complete your review over the phone. When they call, you can schedule your review at a time that is best for you.
• One of Neighborhood’s trusted MTM Program partners. The CVS Caremark Pharmacist Review Team or the Outcomes Patient Engagement Team may call to complete this service.

Different prescribers may write prescriptions for you without knowing all the medications you take. For that reason, the MTM Program health care provider will:

• Review all your medications
• Discuss how your medications may affect each other
• Identify any side effects from your medications
• Help you reduce your prescription drug costs

By completing the medication review with a health care provider, you will:

• Understand how to safely take your medications
• Get answers to any questions you may have about your medications or health conditions
• Review ways to help you save money on your drug costs
• Receive a Recommended To-Do List and Medication List for your records and to share with your prescribers and/or caregivers

The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, Neighborhood will mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you. As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them.

Neighborhood may also contact you directly by mail or by phone with suggestions about your medications.

Please contact us at 1-844-812-6896 (TTY 711) if you would like more information about the Neighborhood Dual CONNECT MTM Program or if you do not want to participate.

The Medicare Prescription Payment Plan is a payment option that works with your drug coverage to help you manage your out-of-pocket costs for drugs covered by our plan by spreading them across the calendar year (January- December). Anyone with a Medicare drug plan or drug coverage can use this payment option.

This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs.

For more information about the Medicare Prescription Payment Plan program, call Member Services at 1-844-812-6896 (TTY 711).

Members with high drug costs – especially those who reach their $2,100 out-of-pocket maximum early in the year – may benefit from the Medicare Prescription Payment Plan program. This payment option may not help individuals who already receive assistance with their drug costs – like from Extra Help⁴ or Medicare Savings Programs.

Neighborhood Dual CONNECT members qualify for and already receive Extra Help from Medicare. This means you might be less likely to benefit from this payment option. Please contact Member Services at 1-844-812-6896 (TTY 711) to learn if this program is right for you.

⁴Extra Help is a Medicare program that helps members with limited income and resources pay for Medicare drug costs.

Neighborhood will send you a letter after we review your request to participate in the Medicare Prescription Payment Plan program.

When you get a prescription for a drug covered by Part D, we will automatically let the pharmacy know that you’re participating in this payment option, and you won’t pay the pharmacy for the prescription.

Each month, Neighborhood will send you a bill with the amount you owe for your prescriptions, when it’s due, and information on how to make a payment.

Remember: Even though you do not pay for your drugs at the pharmacy, you are still responsible for the cost of your medication. To find out how much your drug will cost before you fill your prescription, call Neighborhood or ask the pharmacist.

You will get a reminder notice from Neighborhood if you miss a bill payment. If you do not pay your bill by the due date listed in the reminder, you will be removed from the Medicare Prescription Payment Plan⁵.

You are always required to pay the amount you owe, but in this program you do not have to  pay any interest or fees, even if your payment is late. You can choose to pay what you owe all at once or be billed monthly.

Call Neighborhood if you think there is an error with your Medicare Prescription Payment Plan bill. If you think Neighborhood has made a mistake, you have the right to follow the grievance process found in your Evidence of Coverage (EOC).

⁵If you are removed from the Medicare Prescription Payment Plan, you will still be enrolled in your Medicare health plan.

• You take several high-cost drugs that have a total out-of-pocket cost of $500 each month.
• In January 2026, you join the Medicare Prescription Payment Plan through our plan. We calculate your first month’s bill in the Medicare Prescription Payment Plan differently than your bill for the rest of the months in the year:
  • First, we figure out your “maximum possible payment” for the first month: $2,100 [annual out-of-pocket maximum] – $0 [no out-of-pocket costs before using this payment option] = $2,100 divided by 12 [remaining months in the year] = $175 [your “maximum possible payment” for the first month]
  • Then, we figure out what you’ll pay for January: – Compare your total out-of-pocket costs for January ($500) to the “maximum possible payment” we just calculated: $175. – Your plan will bill you the lesser of the two amounts. So, you’ll pay $175 for the month of January. – You have a remaining balance of $325 ($500-$175).
• For February and the rest of the months left in the year, we calculate your payment differently: $325 [remaining balance] + $500 [new costs] = $825 divided by 11 [11 remaining months in the year] = $75 [your payment for February]
• We’ll calculate your March payment like we did for February: $750 [remaining balance] + $500 [new costs] = $1,250 divided by 10 [remaining months in the year] = $125 [your payment for March]
• We’ll calculate your April payment like we did for March: $1125 [remaining balance] + $500 [new costs] = $1,625 divided by 9 [9 remaining months in the year] = $180.56 [your payment for April]
• In May, when you refill your prescriptions again, you’ll reach the annual out-of-pocket maximum for the year ($2,100 in 2026). You’ll continue to pay what you already owe and get your prescription(s), but after May you won’t add any new out-of-pocket costs for the rest of the year. $1,444.44 [remaining balance] + $100 [new costs] = $1544.44 divided by 8 [8 remaining months in the year] = $193.06 [your payment for May and all remaining months in the year]
• Even though your payment varies each month, by the end of the year, you’ll never pay more than:
  • The total amount you would have paid out-of-pocket.
  • The total annual out-of-pocket maximum ($2,100 in 2026).

You can apply for the Medicare Prescription Payment Plan:

• ONLINE
  Complete Medicare Prescription Payment Plan Participation Request Form on the member portal at www.caremark.com/MPPP
• BY MAIL
  Download (COMING SOON), print, and mail a completed form to the address provided.
• BY PHONE
  Call Member Services at 1-844-812-6896 (TTY 711).

Neighborhood will respond to your request to join the Medicare Prescription Payment Plan within 24 hours if the request is made during the plan year.

For requests made in advance of a new plan year or in advance of a new plan enrollment during the plan year, Neighborhood will process the request within 10 calendar days or the number of calendar days before the plan enrollment starts, whichever is shorter.

If you’re already participating in the Medicare Prescription Payment Plan and stay in the same plan, you don’t need to do anything to stay in the program.

You can opt out of the Medicare Prescription Payment Plan on the member portal or by calling Member Services at 1-844-812-6896 (TTY 711).

You are still required to pay any remaining balance you owe for medications already received through the plan. You will not pay any interest or fees, even if your payment is late. You can choose to pay that amount all at once or be billed monthly.

You can ask to sign up for the Medicare Prescription Payment Plan within 72 hours of the date and time you picked up and paid for your prescription(s) if you believe that any delay in filling your prescription(s) may seriously jeopardize your life, health, or ability to regain maximum function.

Once you are signed up for the program, Neighborhood will reimburse you for the amount you paid for your urgent prescription(s) and any other covered Part D prescription(s) filled between the time you picked up and paid for your urgent prescription(s) and the date that you started the program (within 45 calendar days).

Neighborhood will notify you by mail if we determine that you do not qualify for retroactive enrollment in the Medicare Prescription Payment Plan program and provide you with instructions on how to file a grievance.

There is no difference in the prior authorization, appeal or grievance process for Part D medications whether you are enrolled in Medicare Prescription Payment Plan or not.

Please see the Prior Authorization section on this page for more information.

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.

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.

Click here to find a community safe drug disposal site near you.

You can also mail medications to authorized sites using approved packages. Information on mail-back sites can be found at www.deatakeback.com

You may be able to safely dispose of many medications at home by throwing them in the trash or flushing them down the toilet. Visit the following website first to learn what medications are safe to dispose of at home: https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html

To dispose of medication 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

View the Drug Takeback Flier in English, Spanish, and Portuguese.