Tenn. Comp. R. & Regs. 1200-13-13-.05 - ENROLLEE COST SHARING
(1) TennCare
Medicaid enrollees do not have cost sharing responsibilities for TennCare
coverage and covered services, except TennCare Medicaid adults (age 21 and
older) who receive pharmacy services have nominal copays for the pharmacy
services. The copays are $3.00 (three dollars) for each covered branded drug
and $1.50 (one dollar and fifty cents) for each covered generic drug. Branded
drugs which exceed the limit of two (2) prescriptions or refills per enrollee
per month are not covered. Generic drugs and covered branded drugs which exceed
the limit of five (5) prescriptions or refills per enrollee per month are not
covered. Family planning drugs and emergency services are exempt from copay.
Enrollees may not be denied a service for inability to pay a copay. There is no
Out-of-Pocket Maximum on copays
(2)
The following adult groups are exempt from copay:
(a) Individuals receiving hospice services
who provide verbal notification of such to the pharmacy provider at the point
of service;
(b) Individuals who are
pregnant who provide verbal notification of such to the pharmacy provider at
the point of service; and
(c)
Individuals who are receiving services in a Nursing Facility, an Intermediate
Care Facility for Individuals with Intellectual Disabilities, CHOICES Group 2,
or a Home and Community Based Services waiver for individuals with intellectual
disabilities.
(d) Adults age 21 and
older enrolled in ECF CHOICES who meet nursing facility level of care or
transitioned from a Section 1915(c) waiver into ECF CHOICES and granted an
exception by TennCare based on ICF/IID level of care.
Notes
Authority: T.C.A. §§ 4-5-202, 4-5-208, 4-5-209, 71-5-105, 71-5-109, Acts of 2003, Public Chapter 412, §1(c), and Executive Order No. 23.
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