If you live in Tennessee, TennCare can save you money on medication.
TennCare is a Medicaid program in the state of Tennessee. It works on the Managed Care model, and its purpose is to contract with different health care providers across the state to provide health care at reduced costs. According to the Tennessee government website, it is the oldest of its kind, having begun on Jan. 1, 1994. The plan is responsible for paying Medicare premiums, deductibles or co-insurance for people who otherwise would not be able to pay due to low income. As a patient, you have certain rights and responsibilities, and in order for TennCare to work for you, you need to educate yourself.
Ask Questions
When your physician prescribes medication for you, it is best to ask him how much it will cost you, and if TennCare covers it. If he does not know, ask him for the same or similar medicine that the plan covers. This will save you and him time. It will avoid the frustration of your stepping up to the pharmacy window and requesting the drug, only to find that the drug costs you much more than you expected, and that the state plan will not pay for it. It will also save your doctor the time he would have to spend on the phone to your pharmacist and to TennCare. Should you fail to remember to have that conversation with your physician, you may ask that your pharmacist attempt to contact him.
The Pharmacy's Responsibility to You
In the event that the pharmacist cannot successfully contact your doctor, the pharmacist must give you a three-day supply of medicine under the plan, whether the plan officially covers the medicine or not. The same also holds true if the pharmacist has successfully contacted your physician, but the doctor has not been able to receive a reply from TennCare, which pays your drugstore for this service.
Appeals: Rights and Responsibilities
Should TennCare deny you coverage for medication, you have the right to appeal. This is true whether the program refuses your request for health care, has ended coverage for the particular medication you need, or changed your coverage in any way. You must obtain a copy of the appeal form. You can either call the appeal line at 1-800-560-5747 or download it from the TN Youth Connections website (see References). However, you must act within 30 days of discovering the existence of a problem between you and TennCare.
Emergency Appeals
You also have the right to an emergency appeal if your condition is such that you cannot wait the usual 90-day period. A physician-signed statement that says that your condition could grow worse, affect your vital organs, require a costly hospitalization, or even kill you could expedite the timeline for a decision. The sooner you obtain a doctor's signature, the faster the decision process will move.
Rewards for Reporting Fraud
Practices such as doctor shopping or using the health plan to visit different doctors in an effort to find one who will agree to prescribe a controlled substance constitutes fraud. The Office of Inspector General, which is responsible for investigating such activity, will pay you to report anyone whom you suspect of engaging in this practice. Upon conviction of this individual, the Tennessee Government website will post notice of a guilty verdict. Once this information is on the website, you will have 60 days to claim your monies.
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