Section 1200-13-13-.13 - MEMBER ABUSE OR OVERUTILIZATION OF THE TENNCARE PHARMACY PROGRAM(1) The Bureau is authorized to implement and maintain a Pharmacy Lock-in Program designed to address member Abuse or Overutilization. Activities which may indicate Abuse or Overutilization justifying placement on Lock-in Status or Prior Authorization Status (PA Status) include, but are not limited to, the following: (a) Forging or altering a prescription for drugs.(b) Selling TennCare paid prescription drugs.(c) Visiting multiple prescribers or pharmacies to obtain controlled substances.(d) Trading, swapping or selling a TennCare card.(e) Failing to promptly report the loss or theft of a TennCare card.(f) Forging or altering a TennCare card.(g) Knowingly providing false, incomplete, inaccurate or erroneous information to provider(s) in order to receive covered services for which the member is ineligible.(h) Permitting the use of a TennCare card by anyone other than the member to whom the card is assigned in order to receive or attempt to receive services.(2) The TennCare Pharmacy Lock-in Program shall be administered by the Bureau. Monitoring of enrollee activities listed in Paragraph (1) shall be conducted by the Bureau, the MCCs, including the PBM, and the Tennessee Office of Inspector General (OIG). When an enrollee has been identified as having participated in any Abuse or Overutilization activities, including, but not limited to, the activities listed in Paragraph (1), the enrollee's name shall be referred to the Bureau as appropriate for the Pharmacy Lock-in Program as follows:(a) Any enrollee who has been identified by the OIG as having been convicted of TennCare Fraud or a drug-related offense.(b) Any enrollee who has been arrested for or charged with TennCare Fraud.(c) Any enrollee who has been arrested for or charged with a drug-related offense.(d) Any enrollee who has obtained multiple controlled substance prescriptions over a ninety (90) day period when the prescriptions were filled by three (3) or more different pharmacies and written by three (3) or more different prescribers.(3) Pharmacy Lock-in Program procedures shall include:(a) A determination to place an enrollee who has been referred as appropriate for the Pharmacy Lock-in Program on Lock-in Status shall be made by the TennCare Pharmacy Director or designee after the enrollee's relevant pharmacy claims data has been reviewed by clinical staff.(b) Any enrollee determined to be appropriate for the Pharmacy Lock-in Program shall be notified by the Bureau or the MCC prior to the imposition of Lock-in Status. The notice shall include a brief explanation of the Pharmacy Lock-in Program, the reason for the determination to place the enrollee on Lock-in Status, the date the Lock-in Status will become effective, and the information necessary for the enrollee to appeal the decision of the Bureau, pursuant to Rule 1200-13-13-.11. If the enrollee has an authorized representative on file on their profile, the notice shall be sent to the enrollee's authorized representative.(c) If an enrollee fails to appeal placement in the Pharmacy Lock-in Program or an appeal is not resolved in his favor, the enrollee will be provided TennCare pharmacy services only at the Lock-in Provider to which the enrollee is assigned.(d) Any enrollee who has a diagnosis of malignant neoplasm or sickle cell disease (or sickle cell related disorders outlined in Subpart (iv) of Part 12. of Subparagraph (c) of Paragraph (1) of this rule) shall not be placed in the Pharmacy Lock-in Program. Any enrollee currently in the Pharmacy Lock-in Program shall be removed from the Pharmacy Lock-in Program if the enrollee's medical records indicate one of these diagnoses. However, this exception shall not apply if the enrollee has been arrested for, charged with, or convicted of an activity outlined in Paragraph (1) of this rule (1200-13-13-.13(1)), or been convicted of TennCare Fraud.(4) Lock-in Provider selection. A pharmacy will qualify for and may be selected by the enrollee as a Lock-in Provider only if it meets all the following criteria: (a) It is enrolled in the TennCare Pharmacy Network;(b) It is within the State of Tennessee;(c) It is a full-service pharmacy that carries all medications normally carried by pharmacies;(d) It is not a mail order or specialty pharmacy;(e) It is not a Targeted Pharmacy;(f) It is a single pharmacy location at a specific address. A chain pharmacy may be selected but only the specific named location may be used, not multiple locations or outlets of the chain; and(g) It is in proximity to the enrollee's residence, which must be the current address on file with the Bureau. If no pharmacy is available within fifteen (15) miles of the enrollee's residence, reasonable efforts shall be made to use the nearest qualifying pharmacy.(5) After twelve (12) months a member may request a change of Lock-in Provider once each year. Additional changes are limited to the following reasons: (a) The member has moved and his new address is at least fifteen (15) miles from the lock-in pharmacy and he has updated his address with the Bureau.(b) The member's lock-in pharmacy has permanently closed.(c) The member's lock-in pharmacy has voluntarily dismissed the enrollee from its practice and has notified the Bureau and the PBM.(d) The Bureau may, at its sole discretion, determine that there is a compelling need to change the member's lock-in pharmacy.(6) Review of Lock-in Status. The Bureau or the MCC shall periodically review the claims information of members on Lock-in Status to determine the need for continued lock-in or escalation to Prior Authorization Status. This review shall occur at least one time annually. (a) Lock-in Status will be discontinued if the Bureau determines that a member has met all of the following criteria for at least six (6) consecutive months:1. Has not received any opioid medications while on buprenorphine-containing products for addiction, unless it is established that opioid use was/is appropriate according to the enrollee's provider of addiction therapy.2. Has received TennCare reimbursed controlled substance prescriptions from only one (1) provider, except under the following:(i) If the enrollee is under the care of two (2) providers, and claims data shows consistent, appropriate use of controlled substances within standards of care from both providers, an exception may be made if both providers acknowledge in writing that they are aware of the other provider's care and prescribing and agree that the enrollee is being treated appropriately within standards of care.(ii) Enrollees with claims from multiple providers all in the same practice or in different locations within the same practice will be considered to have used one (1) provider.(iii) Enrollees with claims from multiple BESMART providers will be considered to have used one (1) provider.3. Has received TennCare reimbursed prescriptions from only one (1) pharmacy. However, if the enrollee has changed his or her pharmacy by requesting a Lock-in Provider change that was approved by the Bureau during the review period, an exception may be made to consider the enrollee as having used one (1) pharmacy.(b) If a member is removed from Lock-in Status, the Bureau or the MCC will monitor the member for changes in utilization patterns and return him to Lock-in Status if appropriate under Paragraphs (1)-(3).(7) Prior Authorization Status (PA Status).(a) A member against whom criminal process alleging TennCare Fraud has been issued or who has been convicted of TennCare Fraud shall automatically be placed on PA Status.(b) Lock-in Status shall be escalated to PA Status if a member on Lock-in Status meets three (3) of the following criteria over a 90 day period:1. Has filled prescriptions for controlled substances at three (3) or more pharmacies. However, if the enrollee has changed his or her pharmacy by requesting a Lock-in Provider change that was approved by the Bureau during the review period, an exception may be made to consider the enrollee as having used one (1) pharmacy.2. Has received controlled substance prescriptions from three (3) or more prescribers, except under the following:(i) If the enrollee is under the care of two (2) providers, and claims data shows consistent, appropriate use of controlled substances within standards of care from both providers, an exception may be made if both providers acknowledge in writing that they are aware of the other provider's care and prescribing and agree that the enrollee is being treated appropriately within standards of care.(ii) Enrollees with claims from multiple providers all in the same practice or in different locations within the same practice will be considered to have used one (1) provider.(iii) Enrollees with claims from multiple BESMART providers will be considered to have used one (1) provider.3. Has received an opioid prescription while receiving buprenorphine-containing products for addiction, unless it is established that opioid use was/is appropriate according to the enrollee's provider of addiction therapy.(c) A member who has been treated in a hospital emergency department for an overdose of an illicit controlled substance, as identified in the most recently available TennCare diagnosis data, shall automatically be placed on PA Status.(8) Review of Prior Authorization Status (PA Status). The Bureau or the MCC shall periodically review the claims information of members on PA Status to determine the need for continued PA Status. (a) PA Status for enrollees will be discontinued if TennCare determines that a member has met all of the following criteria for at least six (6) consecutive months: 1. Has not received any opioid medications while on buprenorphine-containing products for addiction, unless it is established that opioid use was/is appropriate according to the enrollee's provider of addiction therapy.2. Has received TennCare reimbursed controlled substance prescriptions from only one (1) provider, except under the following: (i) If the enrollee is under the care of two (2) providers, and claims data shows consistent, appropriate use of controlled substances within standards of care from both providers, an exception may be made if both providers acknowledge in writing that they are aware of the other provider's care and prescribing and agree that the enrollee is being treated appropriately within standards of care.(ii) Enrollees with claims from multiple providers all in the same practice or in different locations within the same practice will be considered to have used one (1) provider.(iii) Enrollees with claims from multiple BESMART providers will be considered to have used one (1) provider.3. Has received TennCare reimbursed prescriptions from only one (1) pharmacy. However, if the enrollee has changed his or her pharmacy by requesting a Lock-in Provider change that was approved by the Bureau during the review period, an exception may be made to consider the enrollee as having used one (1) pharmacy.(b) Enrollees removed from PA Status remain in the Pharmacy Lock-in Program and are required to qualify for removal from the Pharmacy Lock-in Program after a re-review of their prescription claims as described in Paragraph (6) of this rule. If an enrollee is removed from PA Status, TennCare or the MCC will monitor the enrollee for changes in utilization patterns and return the enrollee to PA Status if appropriate under Paragraph (7).(c) Enrollees who are not eligible for review of PA Status:1. When the Bureau has been notified by OIG that an enrollee has been identified as having participated in any Abuse or Overutilization activities, including but not limited to the activities listed in Paragraph (1) of this rule, then that enrollee is not eligible for review of PA Status.2. An enrollee who has been convicted of TennCare Fraud is not eligible for review of PA Status.3. If an enrollee was charged or arrested for TennCare Fraud, the enrollee is not eligible for PA Status review pending the final resolution of the charge or allegation. If the enrollee's TennCare Fraud charges are dismissed or if the enrollee is otherwise not convicted of TennCare Fraud and that TennCare Fraud charge was the sole basis for the enrollee's Lock-in Status, all Pharmacy Lock-in Program and PA Status edits will be terminated on the day that the TennCare Fraud charge was closed.(9) Emergency pharmacy services may be obtained with a TennCare or MCC override of a member's Lock-in Status. The PBM has clinical staff available at all times to respond to emergency situations. The PBM must verify that a genuine emergency exists, such as documented proof from the lock-in pharmacy that it is temporarily out of stock of a needed medication. A lock-in override will not be provided simply because a pharmacy is closed for the day unless a true medical emergency exists.Tenn. Comp. R. & Regs. 1200-13-13-.13
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-.13; new effective date February 12, 2003. Emergency rule filed December 13, 2002; effective through May 27, 2003. Public necessity rule filed December 29, 2005; expired June 12, 2006. On June 13, 2006, affected rules reverted to status on December 28, 2005. Repeal and new rule filed March 31, 2006; effective June 14, 2006. Amendment filed October 3, 2013; effective January 1, 2014. Amendments filed December 29, 2015; effective March 28, 2016. Amendments filed September 11, 2024; effective 12/10/2024.Authority: T.C.A. §§ 4-3-1013, 4-5-202, 4-5-203, 71-5-105, 71-5-109, 71-5-146, 71-5-197, and 71-5-198 and Executive Order No. 23.