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). If you have any questions, contact the OptumRx Pharmacy Supports Center at 866-434-5520 or tnrxeducation@optum.com
Also in Tennessee, TennCare held a webinar on the results of the recent Cost of Dispensing survey. During this event, TennCare disclosed the increased, updated professional dispensing fees (PDFs) applicable to all pharmacies within the TennCare Pharmacy network. Also, beginning November 1, 2023, pharmacies that have not responded to three or more TennCare surveys in the past will have their PDF set at $5.00. Based on the findings, the dispensing fees will be as follows:
Ambulatory
- $13.16 for low-volume pharmacies (<65,000 prescriptions)
- $9.02 for high-volume pharmacies (>65,000 prescriptions)
Specialty
- $52.46 for non-blood factor medications
- $172.69 for blood factor medications
Other
- $13.16 for long-term care
- $16.92 for 340B
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.