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.