Formulary Change for Medicaid and Exchange

Summer 2019

Neighborhood Health Plan of Rhode Island (Neighborhood) is updating its provider-administered, injected or infused, medical benefit drug formulary. After a comprehensive review of pertinent clinical information, the following changes to the Neighborhood Medical Benefit Formulary were recently approved by the Pharmacy and Therapeutics (P&T) Committee. These changes will help keep health care costs as low as possible for everyone, while ensuring our members, your patients, have access to safe and effective prescription drugs.

Effective July 1, 2019, the following products will require step therapy before their use for the Medicaid (EFP, Subcare, CSN, RHP, RHE, RiteCare) and Exchange lines of business (SHOP and Individual):

Therapy Class Drugs with Step Therapy Requirements Alternative Drugs withoutStep Therapy Requirements
Autoimmune Disorders Remicade


Retina Diseases Lucentis


Long-acting Colony-Stimulating Factors Fulphila Neulasta*


Short-acting Colony-Stimulating Factors Neupogen



Enzyme Replacement Therapy Vpriv


Hyaluronic Acids Synvisc-One, Durolane, Genvisc, Hyalgan, Supartz, Visco-3, Hymovis, OrthoVisc, Gel-One, Monovisc, Gelsyn-3, Trivisc Euflexxa
Multiple Sclerosis Lemtrada Tysabri



*These products are covered without a prior authorization on the medical benefit.

Step therapy requirements will apply to new starts ONLY, with the exception of products used for Autoimmune Disorders & Hyaluronic Acids.  For medications in these two classes, once the current authorization has expired, the step therapy requirements will be applied during authorization renewal requests.  The Clinical Medical Policies are posted on the Provider website at

Please contact Neighborhood Health Plan of Rhode Island’s Pharmacy Department with any questions at 401-427-8200.