Section 210-RICR-40-10-1.8 - Prescriptions: Generic PolicyA. For RHP and MMP enrolled members, Medicaid prescription benefits must be for generic drugs. Exceptions for limited brand coverage for certain therapeutic classes may be granted if approved by the Medicaid agency, or the MCO acting in compliance with their contractual agreements with EOHHS, and in accordance with the criteria described below:1. Availability of suitable within-class generic substitutes or out-of-class alternatives.2. Drugs with a narrow therapeutic range that are regarded as the standard of care for treating specific conditions.3. Relative disruptions in care that may be brought on by changing treatment from one drug to another.4. Relative medical management concerns for drugs that can only be used to treat patients with specific co-morbidities.5. Relative clinical advantages and disadvantages of drugs within a therapeutic class.6. Cost differentials between brand and generic alternatives.7. Drugs that are required under federal and State regulations.8. Demonstrated medical necessity and lack of efficacy on a case by case basis.B. For the MMP, the generic policy applies only to Medicaid covered drugs that are not part of the Medicare Part D formulary covered by the MMP. The MMP may cover brand name drugs as part of its Medicare Part D formulary, in accordance with Medicare Part D guidelines.210 R.I. Code R. 210-RICR-40-10-1.8
Amended effective 10/5/2021