Effective October 1, 2024, over the Counter (OTC) COVID-19 testing kits will no longer be covered under TennCare’s pharmacy benefit due to the end of the COVID-19 Public Health Emergency. Beginning October 1, 2024, Covid Test Kits will remain a covered benefit under the medical benefit.

Effective September 1, 2024, TennCare began reimbursing pharmacy providers through the OptumRx Pharmacy Point of Sale System (POS) for the administration of newly FDA approved COVID-19 vaccines for the 2024-2025 Formulas. Per FDA guidance, previous versions of COVID-19 vaccines are no longer recommended or authorized for use. CoverKids and CoverRx claims also follow this FDA guidance.

Claims for COVID-19 vaccines are exempt from co-pays and script limits for all TennCare enrollees.

COVID vaccine claims for dual eligible members (Both Medicare and Medicaid eligible) will receive NCPDP Reject 65 “Patient has Medicare Coverage, Bill Medicare.”

Please note for TennCare members, effective October 1, 2024, the Covid-19 vaccine reimbursement will change to include only the cost of the vaccine plus the Professional Dispensing Fee (PDF). The $40 administration fee will be discontinued. Therefore, the Incentive Amount Submitted (NCPDP Field 483-E3) is no longer required for claim submission. If you have a TennCare Medicaid ID, you may contract with the individual Managed Care Organization(s) to bill for ancillary services. Please contact the designated health plan Provider Services for assistance.

Also in Tennessee, prior authorization requirements can be bypassed for certain medications when specific medical conditions exist. 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). See a list of the preferred agents and the clinical criteria here, and see the list of Tennessee OptumRx Provider Liaisons here.

Finally in Tennessee, the Tennessee Pharmacists Research and Education Foundation (TPREF) is proud to offer an ACPE-accredited OSHA training webinar that meets all of OSHA’s annual training requirements, with ten sessions offered between September 25 and October 23. Register for one of the sessions!

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

During the most recent Board of Pharmacy meeting, the Board confirmed that rules for technician immunizations will not be finalized before the PREP Act expires. However, technicians should still be able to vaccinate after receiving a waiver from the Board’s Executive Director Lucy Shell. NACDS and Tennessee Pharmacy Association are working to confirm details of this process and will share more information as it becomes available.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

TennCare announced the list of covered UPCs for its upcoming diaper program. Luvs, Pampers, Huggies and Cuties are the primary brands that will be covered. If your pharmacy plans to participate and wants to be featured on the TennCare website as a participating location, complete this survey.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

TennCare announced the list of covered UPCs for its upcoming diaper program. Luvs, Pampers, Huggies and Cuties are the primary brands that will be covered. If your pharmacy plans to participate and wants to be featured on the TennCare website as a participating location, complete this survey.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

TennCare Diaper Program website now includes a billing guide, optional diaper request form and survey link for pharmacies to be included on the list of providers that will be available for TennCare and CoverKids members.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

CVS Caremark will contact low-volume pharmacies and pharmacy services administrative organizations (PSAOs) this month with information regarding its re-billing and re-processing updates to comply with 2022’s Public Chapter 1070 for claims from January-October 2023. Due to the switch from AWP to NADAC pricing, some pharmacies may need to pay recoupment fees to CVS Caremark. The Tennessee Pharmacy Association has been in contact with CVS Caremark representatives and legislative leadership and is working to communicate with PSAOs about this change and next steps pharmacies can take to prevent financial losses. Pharmacies should submit rate review requests to CVS Caremark before submitting external appeals to the Department of Commerce and Insurance to rectify this situation.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The TennCare pharmacy diaper program will launch on August 1, 2024. For children ages two years and younger, the program provides access to up to 100 diapers per month per child. Children with TennCare or CoverKids are eligible. Pharmacies can voluntarily participate as access points for the program; an informational webinar for pharmacies will be held on July 9 from 9:00-10:00 am CT.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Prior authorization requirements can be bypassed for certain medications when specific medical conditions exist. 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). See the lists of the preferred agents and the clinical criteria and see the list of Tennessee OptumRx Provider Liaisons.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

This notice is being sent to inform you of changes to the TennCare Pharmacy Program. We encourage you to read this thoroughly and contact OptumRx’s Pharmacy Support Center (866-434-5520) should you have additional questions.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.