Rhode Island § 40-21-3 - Medical Assistance — Prescription Drugs

§ 40-21-3. Preferred drug list.

(a) If a patient’s healthcare provider prescribes a prescription drug that is not on the preferred drug list, the prescriber shall consult with the program to confirm that, in his or her reasonable professional judgment, the patient’s clinical condition is consistent with the criteria for approval of the nonpreferred drug. Such criteria shall include:

(1) The preferred drug has been tried by the patient and has failed to produce the desired health outcomes;

(2) The patient has tried the preferred drug and has experienced unacceptable side effects;

(3) The patient has been stabilized on a nonpreferred drug and transition to the preferred drug would be medically contraindicated; or

(4) Other clinical indications identified by the committee for the patient’s use of the nonpreferred drug, which shall include consideration of the medical needs of special populations, including children, elderly, chronically ill, persons with mental health conditions, and persons affected by HIV/AIDS.

(b) In the event that the patient does not meet the criteria in subsection (a), the prescriber may provide additional information to the program to justify the use of a prescription drug that is not on the preferred drug list. The program shall provide a reasonable opportunity for a prescriber to reasonably present his or her justification of prior authorization. If, after consultation with the program, the prescriber, in his or her reasonable professional judgment, determines that the use of a prescription drug that is not on the preferred drug list is warranted, the prescriber’s determination shall be final.