Tenn. Comp. R. & Regs. 1200-13-13-.15 - BESMART

This rule supersedes any other rules related to the use of buprenorphine products for treatment of opioid use disorder (OUD) in office based opioid treatment (OBOT) or an opioid treatment program (OTP) by a treating provider participating in an MCO's network of BESMART providers.

(1) BESMART treatment is a component of covered outpatient substance abuse benefits and consists of a set of coordinated medically necessary covered services which includes:

(a) Psychosocial assessment and development of a treatment plan;

(b) Individual or group counseling;

(c) Peer recovery services;

(d) Care coordination;

(e) Opioid-agonist therapy consisting of buprenorphine products that have been FDA approved for OUD treatment and may be prescribed in excess of the limits described in rules .04 and .10, when determined to be medically necessary by a treating provider in an MCO's network of BESMART providers and under the participant's plan of care.

1. Except as otherwise provided for in this rule, participants may receive up to sixteen (16) mg of buprenorphine containing products daily; however, providers shall initiate and lead a discussion regarding a participant's readiness to taper down or off treatment at any time upon a participant's request, but no later than one (1) year after initiating treatment and every six (6) months thereafter.

2. Under the best practices for treatment of OUD, the BESMART provider shall utilize the lowest effective dose of Medication-Assisted Treatment (MAT).

3. The following adult populations shall be eligible to receive a maximum daily dosage of twenty-four (24) mg of buprenorphine, not to exceed one (1) year in duration:

(i) Pregnant participants confirmed by provider attestation.

(ii) Postpartum participants for a period of twelve (12) months from delivery date as shown by medical records or insurance claim.

(iii) Recent intravenous (IV) drug users confirmed by prescriber attestation and a positive urine drug screen.

(iv) Current users receiving greater than fifty (50) mg of methadone for OUD treatment transitioning to buprenorphine agonist therapy demonstrated by paid claims data from the participant's health insurer, provider attestation, or medical records.

(v) Current users of sixteen (16) mg to twenty-four (24) mg per day of buprenorphine demonstrated by paid claims data from the participant's previous health insurer.

(vi) For one (1) year from the effective date of this rule, a member who does not qualify under the criteria of this part but receives greater than sixteen (16) mg per day of buprenorphine as demonstrated by the controlled substance monitoring database shall be eligible to receive a maximum daily dose of twenty-four (24) mg.

(2) BESMART treatment requires medical office visits at least weekly for participants in the induction and stabilization phase of treatment; at least every two (2) to four (4) weeks for participants in the maintenance phase of treatment; and at least every two (2) months for participants who have been in the maintenance phase of treatment for one (1) year or longer.

(3) To be reimbursed for a BESMART covered service, treating providers must demonstrate an ability to provide all BESMART services in a coordinated, person-centric way, including the ability to facilitate access to all related treatment modalities and provider types, and must participate in at least one (1) MCO's network of BESMART providers.

(4) Prescriptions of buprenorphine containing products to TennCare enrollees by nurse practitioners and physician assistants for the treatment of OUD will not be reimbursed unless the nurse practitioner or physician assistant participates in at least one (1) MCO's network of BESMART providers.

Notes

Tenn. Comp. R. & Regs. 1200-13-13-.15

Emergency rules filed April 15, 2021; effective through October 12, 2021. New rule filed June 29, 2021; effective 9/27/2021.

Authority: T.C.A. §§ 4-5-202, 4-5-208, 71-5-105, 71-5-107, and 71-5-109.