SB 2499

Present law requires m edical assistance, including demonstration projects and programs designed to enhance the efficient and economic operation of TennCare , to be provided to those classes of individuals determined to be eligible . Present law provides a list of services that may be deemed medical assistance. This bill adds to such list l ong-acting injectable drugs intended for treatment and prevention of HIV and administered in a pharmacy, physician's office, clinic, ambulatory surgical treatment center, or hospital . Additionally, this bill requires a managed care organization (MCO) or pharmacy benefits manager (PBM) to reimburse a claim for a long-acting injectable drug (i) i ntended for treatment and prevention of HIV and ( ii ) a dministered in a pharmacy, physician's office, clinic, ambulatory surgical treatment center, or hospital. An MCO or PBM that covers such a claim as a medical benefit or service must also cover any such claim as a pharmacy benefit . However, the MCO or PBM must only reimburse a provider for eac h individual treatment or service provided , and a n individual provider may only be reimbursed for each claim under either the pharmacy benefit or the medical benefit or service. This bill applies to an MCO or PBM that is contracted with the bureau of TennCare to administer and provide or reimburse for medical or pharmacy services for TennCare enrollees on behalf of the bureau.