Rules & Regulations of the State of Tennessee
Title 0780 - Commerce and Insurance
Subtitle 0780-01 - Insurance Division
Chapter 0780-01-95 - Pharmacy Benefits Managers
Section 0780-01-95-.08 - PLANS UTILIZING A REIMBURSEMENT METHODOLOGY IDENTICAL TO THE METHODOLOGY USED BY THE STATE PLAN FOR MEDICAL ASSISTANCE APPROVED BY THE FEDERAL CENTERS FOR MEDICARE AND MEDICAID SERVICES

(1) As used in T.C.A. § 56-7-3206(d)(2), a reimbursement methodology is identical to the methodology provided for in the state plan for medical assistance approved by the federal Centers for Medicare and Medicaid Services if the reimbursement methodology is identical in all respects, including, but not limited to, that requests for reimbursement are submitted to the Division of TennCare as set out in that methodology and the methodology complies with the Division of TennCare Pharmacy Provider Manual, or a successor manual, as amended or updated, and all laws and rules of the Division of TennCare related to reimbursement.

(2) A pharmacy that alleges it did not receive at least its actual cost for a prescription drug or device after resolution of an appeal filed with a PBM pursuant to T.C.A. § 56-7-3206(d)(2) shall appeal the decision to the Division of TennCare as set out in the applicable laws and rules. Such appeals are not subject to review or appeal under this chapter.