Current through September 24, 2024
(1)
(a) To
determine whether a pharmacy's annual prescription volume for calendar year
2023 is at a level that, if the pharmacy were a TennCare-participating
ambulatory pharmacy, would qualify the pharmacy for the enhanced professional
dispensing fee for a low-volume pharmacy, each pharmacy that expects to qualify
as a low-volume pharmacy for calendar year 2023 shall file with a PBM from whom
the pharmacy expects to receive a dispensing fee during 2023 a certification
stating the pharmacy expects to qualify as a low-volume pharmacy for calendar
year 2023. Each certification shall contain a statement that the certification
is true and accurate to the best of the knowledge of the individual filing the
certification on behalf of the pharmacy.
(b) Beginning with certifications made for
dispensing fees to be paid during calendar year 2024, to determine whether a
pharmacy's annual prescription volume is at a level that, if the pharmacy were
a TennCare-participating ambulatory pharmacy, would qualify the pharmacy for
the enhanced professional dispensing fee for a low-volume pharmacy, each
pharmacy that will qualify as a low-volume pharmacy, as determined pursuant to
subparagraph (2)(b) of this rule, shall, on or before December 1 of each year,
file with a PBM from whom the pharmacy expects to receive a dispensing fee a
certification stating the pharmacy will qualify as a low-volume pharmacy for
the coming calendar year. Each certification shall contain a statement that the
certification is true and accurate to the best of the knowledge of the
individual filing the certification on behalf of the pharmacy. The pharmacy's
certification submitted, or failure to submit a certification, pursuant to this
paragraph shall determine the pharmacy's dispensing fee for the respective
calendar year, unless a pharmacy submits a certification pursuant to paragraphs
(3) or (4) of this rule.
(c) Upon
receipt of a pharmacy's certification pursuant to subparagraph (1)(b) of this
rule, the PBM shall pay the pharmacy the appropriate dispensing fee for
prescriptions filled on or after January 1 of the calendar year for which the
certification was submitted. Except as provided in Tenn. Code Ann. §
56-7-3103, a PBM may not recoup
any portion of a dispensing fee from a pharmacy that accurately certifies its
annual prescription volume.
(2)
(a) When
submitting a certification pursuant to subparagraph (1)(a) of this rule, a
pharmacy shall base the determination of whether its prescription volume for
the coming calendar year will qualify the pharmacy for the enhanced
professional dispensing fee on the pharmacy's actual prescription volume from
July 1, 2021, to June 30, 2022.
(b)
When submitting a certification pursuant to subparagraph (1)(b) of this rule, a
pharmacy shall:
1. Base the determination of
whether it will qualify for the enhanced professional dispensing fee on the
pharmacy's actual prescription volume from July 1 of the year prior to the year
during which the certification is due to June 30 of the year during which the
certification is due. For example, certifications submitted on or before
December 1, 2024, for calendar year 2025 shall be based on a pharmacy's actual
prescription volume from July 1, 2023, to June 30, 2024; and
2. Along with the certification, submit proof
of the pharmacy's actual prescription volume, which may be in the form of
aggregate claims data or similar information. A pharmacy's certification shall
not be considered complete until the pharmacy has also submitted proof pursuant
to this part.
(3) If a pharmacy fails to timely submit a
certification pursuant to paragraph (1) of this rule with a PBM with whom the
pharmacy has an ongoing business relationship, the pharmacy shall be presumed
to be a high-volume pharmacy. However, if a pharmacy later certifies it
qualifies for the enhanced professional dispensing fee for a low-volume
pharmacy by meeting the requirements of parts 1. and 2. of subparagraph (2)(b)
of this rule, the PBM shall pay the certifying pharmacy the enhanced
professional dispensing fee for prescriptions dispensed beginning on the
seventh business day after the PBM receives the complete
certification.
(4) If a pharmacy
receives, or expects to receive, a dispensing fee from a PBM with whom the
pharmacy did not anticipate doing business at the time the pharmacy was
required to file the certification under paragraph (1) of this rule, the
pharmacy shall file the certification with the PBM simultaneously with the
claim for reimbursement or within one business day of discovering the need to
file the certification, whichever is later. The certification submitted
pursuant to this paragraph must meet the requirements of parts 1. and 2. of
subparagraph (2)(b) of this rule. The PBM shall pay the certifying pharmacy the
enhanced professional dispensing fee for prescriptions dispensed on or after
the day the PBM receives the complete certification.
(5) For calendar year 2023, a pharmacy shall
file the certification required under paragraph (1)(a) of this rule on or
before January 31, 2023. Until a pharmacy files the certification required
under paragraph (1)(a) of this rule, the pharmacy shall be presumed to be a
high-volume pharmacy and shall not qualify for the enhanced professional
dispensing fee for a low-volume pharmacy. If a pharmacy certifies it qualifies
for the enhanced professional dispensing fee for a low-volume pharmacy, the PBM
shall pay the certifying pharmacy the enhanced professional dispensing fee for
prescriptions dispensed on or after the seventh business day after the PBM
receives the certification.
Authority: T.C.A. §§
56-7-3101 and
56-7-3206.
