New Rhode Island Medicaid Managed Care Contract - Ubhonline.com

2. Open (Select) Provider Model – Moderate Intensity
Members will be enrolled in this model if they:
Account for $10,000 or more in total Medicaid (health plan) expenses within the last
calendar year.
Do NOT meet criteria for Dedicated Provider Model.
Members enrolled in this model will receive telephonic outreach, during which they will be
asked to complete an ED Health Assessment. Based on results, they will be eligible for
Enhanced Case Management.
3. Open (Select) Provider Model – Light Intensity
Members will be enrolled in this model if they:
Account for less than $10,000 in total Medicaid (health plan) expenses within the last
calendar year.
Do NOT meet criteria for Dedicated Provider Model.
A member enrolled in this model will receive an outreach letter, resource materials (as
appropriate) and an ED Health Assessment to return by mail. UnitedHealthcare will review
returned ED Health Assessment to determine if the member requires further intervention.
We appreciate your help in ensuring the delivery of excellent medical care to our members.
Generic First Program Expanded to Rhody Health Partners and Children with
Special Needs
Effective October 1, 2010, as part of State contract requirements, the Generic First
Pharmacy Program, currently in place for RIte Care Members, will be expanded to include
both the Rhody Health Partner (RHP) and Children with Special Healthcare Needs (CSN).
The program allows a limited number of brand name drugs for certain therapeutic classes of
drugs. On a case-by-case basis, additional brand name drugs may be available based on
medical necessity and demonstrated lack of efficacy of available generic alternatives.
Medical necessity reviews will be available according to UnitedHealthcare’s protocols.
Members currently being prescribed medications that must be deleted from the
UnitedHealthcare Formulary have been notified of this change to their Pharmacy benefit,
and the need to contact their physician. UnitedHealthcare has also sent letters to physicians
identifying patients who will be impacted by this change.
Medications that have been deleted from the Preferred Drug List must be replaced with a
generic alternative. For those cases, where the prescriber deems that the preferred generic
alternatives may not be appropriate or adequate, requests for authorization can be made
using our standard process. Approvals will be based upon a medical necessity review.
Continuity of care will not suffice to show medical necessity.
This change does not affect patients with traditional Medicaid Fee-For-Service coverage.
We recognize that this change may raise concerns for some Rhody Health Partners and CSN
members. We are asking for your assistance in making this transition as smooth as