Section 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.Tenn. Comp. R. & Regs. 1200-13-13-.05
Public necessity rule filed July 1, 2002; effective through December 13, 2002. Original rule filed September 30, 2002; to be effective December 14, 2002; however, on December 9, 2002, the House Government Operations Committee of the General Assembly stayed rule 1200-13-13-.05; new effective date February 12, 2003. Emergency rule filed December 13, 2002; effective through May 27, 2003. Amendment by Acts of 2003, Public Chapter 412, §1(c) filed and effective June 25, 2003. Public necessity rule filed July 1, 2005; effective through December 13, 2005. Amendment filed September 26, 2005; effective December 10, 2005. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendment filed May 27, 2010; effective August 25, 2010. Emergency rule filed September 26, 2013; effective through March 25, 2014. Amendment filed December 17, 2013; effective March 17, 2014. Emergency rules filed July 1, 2016; effective through December 28, 2016. Amendments filed September 30, 2016; effective 12/29/2016.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.