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The Executive Office of, Health and Human Services , State of Rhode Island

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Agency Announcements

RIBridges Alert

Alert for Health and Human Services customers about a recent data breach. Click here for more info.

Fair Hearing - How to Request Without Web (Mail, Call, Visit)

While the web portal (RIBridges and/or the HealthyRhode Mobile App) is not available, fair hearings can only be requested by phone, in person, or by mail. To schedule a fair hearing by phone, please call 1-855-697-4347. To request a fair hearing by mail or in person, please visit or address the materials to your local DHS office.

For more information about the fair hearing process, please visit the Appeals Office page.

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Pharmacy Prior Authorization Program

Prior Authorization (PA) Cheat Sheet

Forms

Prior Authorization for Non-Preferred Drug Form
PA01 - Modafinil
PA02 - CNS Stimulants
PA04 - Weight Loss
PA05 - Follicle Stimulation
PA06 - Growth Hormone
PA09 - Botulinum Toxins
PA10 - Agents Treating Pulmonary Hypertension
PA11 - Fuzeon
PA16 - Chronic Idiopathic Constipation
PA17 - Qualaquin
PA18 - Megace ES
PA20 - Pradaxa
PA21 - Xifaxan (550mg)
PA22 - Treatment for Hepatitis C
- Sample Patient Contract for receiving treatment for Hepatitis C
PA23 - Opioids
PA24 - Yescarta_Kymriah
- PA24 - Yescarta_Kymriah Coverage Guidelines for Modified T-Cell Therapies
General Pharmacy Prior Authorization Form

Executive Office of Health and Human Services
3 West Road
Cranston, RI 02920

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