TennCare Pharmacy Program c/o Magellan Health Services West Broad Street, Suite 500 Glen Allen, Virginia 23060

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1 PBM 3 NCov Handout.7 TennCare Pharmacy Program c/o Magellan Health Services West Broad Street, Suite 500 Glen Allen, Virginia Do you need special help? Call for free. Versión en español atrás. The federal government says doctors who take Medicaid must write prescriptions on special paper. It s called a tamper resistant prescription pad. On, you asked TennCare to pay for your prescription for this medicine or medicines: TennCare can t pay for this medicine because the prescription was written on the wrong kind of paper. That means it s not a covered benefit. ( Benefits are the care and medicine TennCare pays for.) The federal government, Tennessee law, and TennCare rules give the State the right to not cover this drug. [42 U.S.C. 1396r-8 (d), 1396b (i)(23); State Plan Amendment TN (6/1/05); State Plan Amendment TN (effective 1/1/06); TCA (d); Tenn.Comp.R.&Regs , , , ] Do you think we made a mistake? Did your doctor use a tamper resistant prescription pad? If so, you can file an appeal. How to File a TennCare Appeal You have 60 days from the date on this page to appeal. During your appeal, we won t pay for this drug. But, if you win your appeal, you can ask us to pay you back. After 60 days, it s too late to appeal. When you appeal, you re asking to tell a judge the mistake you think TennCare made. It s called a fair hearing. Reasons you can have a fair hearing may include: Your doctor did use a tamper resistant prescription pad to write your prescription on. Federal law says your pharmacist can only take a written prescription on this kind of paper. If we decide you re right, we ll pay for this medicine. What if we decide you re wrong? If you still think we made a mistake about a fact, you can have a fair hearing. If you don t think we made a mistake about a fact, you can t have a fair hearing. 1

2 You don t have a right to a fair hearing just because you don t like this decision or think it will cause problems for you. This means that you won t get a hearing if the only reason for your appeal is something like: You think TennCare should pay for this medicine that it should be a covered benefit. You re taking this medicine now. You think TennCare has paid for this medicine before for you or someone else. This medicine is used to treat a health or mental health problem that you have. You don t have any other way to pay for this medicine. You don t agree with the law that says doctors must use a tamper resistant prescription pad. You or your doctor thinks this medicine is medically necessary. But, TennCare won t pay for it. People who lie on purpose to get TennCare services may be fined or sent to jail. To decide your appeal, here s what you must tell us in your appeal: Your name (the name of the person who needs the medicine) Your Social Security number or the number on your TennCare card. (If you don t have those numbers, give us your date of birth. Include the month, day, and year.) The name of the medicine you asked TennCare to pay for The mistake you think TennCare made for example that: Your doctor did use a tamper resistant prescription pad to write your prescription on. To be sure we can reach you about your appeal, please also tell us: Your current mailing address The name of the person we should call if we have questions about your appeal A daytime phone number for that person Is your appeal for medicine you ve already gotten and paid for? Are you asking to be paid back? If so, then you must also tell us: The date you got the medicine The name of the drug store where you got it. (If you have it, include the drug store s address and phone number.) And, you must fax or mail us A copy of a receipt that proves you paid for the medicine; and A note signed by the pharmacy you gave the prescription to. The note must say the prescription was: Written on tamper resistant paper; or Called in by phone or faxed in; or Sent to the pharmacy from the doctor s office computer (electronically). If you don t give us all of the information we need, we may not be able to decide your appeal. You may not get a fair hearing. 2

3 After you get your information together, there are 3 ways to file an appeal. Remember: You only have 60 days from the date on page 1 to appeal. 1. Mail. You can mail an appeal page or a letter about your problem to: TennCare P.O. Box Nashville, TN You can get an appeal page from our website. Go to tn.gov/tenncare. Click For Members/Applicants then click on File a Medical Appeal. Or, to have TennCare mail you an appeal page, call them for free at Or fax. You can fax your appeal page or letter for free to Or call. You can call TennCare for free at We re here to help you Monday through Friday from 8:00 a.m. until 4:30 p.m. Central Time. Do you think you have an emergency? Usually, your appeal is decided within 90 days after you file it. But, if you have an emergency and <PBM name> agrees that you do, you will get an expedited appeal. An expedited appeal will be decided in about one week. It could take longer if <PBM name> needs more time to get your medical records. An emergency means that waiting 90 days for a yes or no decision could put your life or physical or mental health in real danger. Do you still think you have an emergency? If so, you can ask TennCare for an expedited appeal by calling Your doctor can also ask for this kind of appeal for you. But the law requires your doctor to have your permission (OK) in writing. Write your name, date of birth, your doctor s name, and your permission for them to appeal for you on a piece of paper. Then fax or mail it to TennCare (see There are 3 ways to file an appeal for our address and fax number). What if you don t send us your OK and your doctor asks for an expedited appeal? TennCare will send you a form to fill out, sign, and send back. After you give your OK in writing, your doctor can help by completing a Provider s Expedited Appeal Certificate. Your doctor can get the page from TennCare s website. Go to tn.gov/tenncare. Click Providers, and then click Miscellaneous Provider Forms. Your doctor should fax this certificate and your medical records to TennCare. TennCare and <PBM name> will look at your appeal and decide if it should be expedited. If it should be, you will get a decision on your appeal in about one week. Remember, it could take longer if <PBM name> needs more time to get your medical records. 3

4 But, some kinds of care are never treated as an emergency. To get a list of those kinds of care, ask TennCare. The list includes drugs that are not covered by TennCare. If you ask for an expedited appeal, we ll take another look. What if we still think this medicine is not covered? Then, TennCare can t give you an expedited appeal, even if you or your doctor asks for one. TennCare will decide your appeal within 90 days. Do you need help with this letter or filing an appeal? Is it because you have a health, mental health, or learning problem or a disability? Or, do you need help in another language? If so, you have a right to get help, and TennCare can help you. Call us at Do you have a mental illness and need help with this letter? The TennCare Advocacy Program can help you. Call them for free at If you have a hearing or speech problem, you can call TennCare on a TTY/TDD machine. Our TTY/TDD number is If you are on TennCare, interpretation and translation services are free. Call the member service number on your TennCare card. Habla español y necesita ayuda con esta carta? Llámenos gratis al We do not allow unfair treatment in TennCare. No one is treated in a different way because of race, color, birthplace, religion, language, sex, age, or disability. Do you think you ve been treated unfairly? Do you have more questions or need more help? If you think you ve been treated unfairly, call the Family Assistance Service Center for free at In Nashville, call

5 TN A Do You Need Special Help? Here are some places you can call for help. All of these numbers are free calls. Se incluye la versión en español Do you have questions or need help with TennCare? Or, do you need help because you have a health, mental health, learning problem or disability? Call the Tennessee Health Connection at Do you have a hearing or speech problem and have questions or need help? Call the Tennessee Relay Service (TNRS) at Ask them to connect you with the Tennessee Health Connection at Do you need help with prescription or refills at the drug store? First, call your doctor. Then, if you still need help call the TennCare Solutions Unit at Do you have questions about Medicare for people over age 65 and for the disabled? Call Tennessee s State Health Insurance Assistance Program (SHIP) at Do you need help getting health care, mental health care or drug or alcohol treatment? First, call your health plan. If you still need help call the TennCare Advocacy Program at Then, if you still need help, call the TennCare Solutions Unit at

6 TN A Do you need help talking with us or reading what we send you? Do you have a disability and need help getting care or taking part in one of our programs or services? Or do you have more questions about your health care? Call us for free at We can connect you with the free help or service you need. (For TTY call: ) We obey federal and state civil rights laws. We do not treat people in a different way because of their race, color, birth place, language, age, disability, religion, or sex. Do you think we did not help you or you were treated differently because of your race, color, birth place, language, age, disability, religion, or sex? You can file a complaint by mail, by , or online. Here are two places where you can file a complaint: TennCare Office of Civil Rights Compliance 310 Great Circle Road, Floor 3W Nashville, Tennessee HCFA.Fairtreatment@tn.gov Phone: (TRS 711) You can get a complaint form online at: U.S. Department of Health & Human Services Office for Civil Rights 200 Independence Ave SW, Rm 509F, HHH Bldg Washington, DC Phone: (TDD): You can get a complaint form online at: Or you can file a complaint online at:

7 TN A014.6 Do you need free help with this letter? If you speak a language other than English, help in your language is available for free. This page tells you how to get help in a language other than English. Spanish: Español ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Kurdish: پەیوەندی بە Arabic: کوردی ئاگاداری: ئەگەر بە زمانی کوردی قەسە دەکەیت خزمەتگوزاریەکانی یارمەتی زمان بەخۆڕایی بۆ تۆ بەردەستە. ( ( TTY بکە. ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم : (. العربية Chinese: 繁體中文注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY ) Vietnamese: Tiếng Việt CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Korean: 한국어주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. French: Français ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: ). Amharic: አማርኛ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: ). Gujarati: ગ જર ત સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ). Laotian: ພາສາລາວ ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: ).

8 TN A014.6 German: Deutsch ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Tagalog: Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Hindi: ह द ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ) पर क ल कर Serbo-Croatian: Srpsko-hrvatski OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ). Russian: Русский ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Nepali: न प ल ध य न हदन स: तप र इ ल न प ल ब ल न न छ भन तप र इ क ननम तत भ ष स यत स व र नन श ल क र पम उपलब ध छ फ न गन स (ह ह व र इ: ) Persian: توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت باشد. با ( (TTY: تماس بگیرید. رایگان فارسی برای شما می فراهم