Pharmacy
Provider Representative: Ann Bennett Tel.(571) 895-6866
email Ann.Bennett2@gainwelltechnologies.com
Please Note: Consumers with questions regarding prescriptions please contact your case manager.
Program Information
- Drug Utilization Review
- OTC Listing January 2024
- Pharmacy Prior Authorization Program
- Pharmacy and Therapeutics Committee
- Request for Out of State Pharmacy Services
- General Public Assistance (GPA) Drug Formulary
- RI State Maximum Allowable Cost (MAC) List
- Fee-for-Service Preferred Drug Lists
- Carve-Out Drugs List
Reference Guide
News
CMS Cell and Gene Therapy (CGT) Access Model
RI EOHHS policy for both Fee for Service (FFS) and Managed Care beneficiaries effective January 2026. Prior Authorization (PA) requests will be administered by the beneficiary's plan. Please verify eligibility and submit the PA to the appropriate plan.
Updates to our Third-Party Liability (TPL) Claims Processing System
In full compliance with new federal requirements, EOHHS is updating its system rules. Moving forward, claims will be automatically denied when another insurance carrier (excluding Medicare) has previously refused payment solely on the basis that prior authorization was not obtained under that carrier's specific rules.
Pharmacy claims for FFS Medicaid submitted with the Other Coverage Code (OCC)03 and receiving the following NCPDP reject codes from the primary must submit those reject codes to Medicaid:
Code 75: Prior Authorization Required
Code 3W: Prior Authorization in Process
Code 3Y: Prior Authorization Denied
Effective April 1, 2026
Please see updated payer sheet below.
Frequently Asked Questions (FAQ's)
- Policy for the Treatment of Hepatitis C (Updated January 1, 2022)
- Where can I find the list of J Codes that require an NDC?
- Where can I find information about the RI AIDS Drug Assistance Program (ADAP)?
- Billing Part B Medications
- DUR Alert Override Codes
- Lost or Stolen Prescription Form and Instructions
- CMS List of Rebateable Drug Manufacturers
- Can pharmacies bill for administering vaccines?
No. Billing for administering vaccines is submitted by a medical provider in the Fee-for-Service Medicaid Program. For more information on vaccines go to: October 2018 Provider Update - How to bill NDCs on the CMS-1500 Form
- NCPDP D.0 Payer Sheet (Effective 4/1/2026)
- DESI Drug List (January 2025)
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Do Smoking Cessation Products need a prior authorization? No, effective January 2014 no prior authorization is needed.