To assist prescribers and providers, prior authorization (PA) requirements can be bypassed for certain medications when specific medical conditions exist. Those specific medications and diagnoses can be found here. Prescribers are encouraged to include the applicable diagnosis code on written prescriptions for inclusion on the electronic pharmacy claim. The submitted claim should include a Diagnosis Code Qualifier (Field # 492-WE) of “02,” indicating ICD-10, as well as the appropriate Diagnosis Code (Field # 424-DO). We encourage you to review this information thoroughly and contact the OptumRx Pharmacy Supports Center at 866-434-5520 or tnrxeducation@optum.com should you have questions.
Also in Tennessee, TennCare is continuing the process of reviewing all covered drug classes. Changes to the PDL may occur as new classes are reviewed, and previously reviewed classes are revisited. As a result of these changes, some medications your patients are now taking may be considered non-preferred agents in the future. Please inform your patients who are on these medications that switching to preferred products will decrease delays in receiving their medications. We encourage you to read this notice thoroughly and contact OptumRx’s Pharmacy Support Center (866-434-5520) or tnrxeducation@optum.com should you have additional questions. For more details on Clinical Criteria, please visit https://www.optumrx.com/oe_tenncare/landing.
Finally in Tennessee, effective July 1, 2023, TennCare members will be able to obtain Continuous Glucose Monitors (CGMs) and supplies from their local in network retail pharmacy. This new coverage pathway will not affect coverage under the medical plan. This update allows TennCare members to access CGMs and related supplies through either their pharmacy OR medical program. Under this new coverage pathway, prescriptions for CGMs and maintenance supplies may be sent to your patient’s in-network pharmacy of choice. We encourage you to read this notice thoroughly and contact OptumRx’s Pharmacy Support Center (866-434-5520) or tnrxeducation@optum.com should you have additional questions.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.