Section 0780-01-95-.10 - DETERMINATION OF PHARMACY'S PROFESSIONAL DISPENSING FEE(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; and2. 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.Tenn. Comp. R. & Regs. 0780-01-95-.10
Emergency rules filed December 29, 2022; effective through June 27, 2023. New rules filed March 29, 2023; effective 6/27/2023.Authority: T.C.A. §§ 56-7-3101 and 56-7-3206.