Tennessee PBM Reform Resource Hub
TPA has compiled these resources for Tennessee pharmacies to navigate PBM issues, including: appeals, complaints, and dispensing fees to comply with state PBM reform laws and regulations.
TPA continues to advocate for increased transparency and accountability for Pharmacy Benefits Managers (PBMs) at the state level. These enacted laws ensure that pharmacies have the ability to maintain a level playing field with respect to the practices of PBMs. Ongoing state advocacy efforts include protections for patient access to pharmacist-provided care, pharmacy audit restrictions, increased transparency and accountability for pharmacy payments from PBMs, and other essential PBM reform laws.
It is important to note that any laws enacted in Tennessee or any other state cannot be enforced on federally-funded programs, such as TRICARE or Medicare plans. The information provided below can help guide pharmacies in handling concerns with PBMs managing commercial health plans. For more information on TennCare, please visit here.
Overview of Recent PBM Reform in Tennessee
In 2021, Public Chapter 569 was adopted to demonstrate the need for fair reimbursement and ability to serve as any willing provider for commercial insurance plans. In 2022, this was updated as Public Chapter 1070 to requires PBMs to follow clear rules for reimbursements, appeals, and pharmacy choice. The Tennessee Department of Commerce & Insurance (TDCI) enforces these requirements.
Pharmacies now have standardized tools to appeal reimbursement decisions, request external reviews, and report PBM violations.
Deadlines at a Glance
- 7 business days – File an initial appeal with the PBM after a reimbursement decision.
- 5 business days – If the appeal form is incomplete, you must correct and resubmit.
- 7 business days – PBM must respond to your initial appeal.
- 30 calendar days – If denied, you can request an external appeal to TDCI/Myers & Stauffer.
- 10 business days – PBM must respond to TDCI on external appeal.
- 90 calendar days – Final external appeal decision issued.
- 5 business days – PBM must pay after a favorable appeal decision.
How to File an Appeal
Step 1: Initial Rate Review Request through the PBM
- Use the PBMs proper channels to submit a rate review request when a payment is not covering the cost to the pharmacy for a brand or generic medication.
- PBMs are required to use a standard format for pharmacy reimbursement appeals.
- Communicate with your PSAO or Corporate Office to verify what part of this process may be handled for you.
- Submit within 7 business days of the clean claim decision. Be ready to include supporting documentation (invoice, proof of acquisition cost, claim detail).
- PBM must respond within 7 business days.
- Upon a denied request or an approval that still doesn’t cover your full cost associated with medication, proceed to next step.
Step 2: External Appeal to TDCI/Myers & Stauffer
- If denied, request an external appeal within 30 calendar days of the PBM’s decision.
- File online through the Myers & Stauffer portal.
- Attach the original appeal, PBM’s response, and supporting documentation.
- The external reviewer issues a final decision within 90 days.
If the decision favors the pharmacy, the PBM must pay within 5 business
Filing a Complaint
Separate from the appeal process for reimbursement of drug product, pharmacies may also file a complaint with TDCI if a PBM engages in prohibited conduct (e.g., steering patients, failing to follow appeal timelines).
- Use the TDCI PBM Complaint Form (online submission).
- Provide claim examples, PBM correspondence, and documentation.
- Complaints help TDCI track systemic PBM issues.
TDCI will work to address complaints pertaining to:
- Initial Reimbursement appeal process, notice or timely payment: PBM failing to follow requirements for initial appeal process. Tenn. Comp. R. & Regs. 0780-01-95-.04 &.05
- Dispensing Fee: Insurer or PBM failing to pay the appropriate dispense fee to a low-volume pharmacy. T.C.A. § 56-7-3206
- Steering: Insurer or PBM interfering with an insured’s right to choose a contracted pharmacy. T.C.A. § 56-7-3120
- Audits: Insurer or PBM failing to comply with statutory requirements for audits of pharmacy/pharmacist. T.C.A. § 56-7-3103
- Prompt Pay for clean pharmacy claims: PBM failing to comply with Prompt Payment Standards for clean pharmacy claims T.C.A. § 56-7-3124
- Step Therapy: Insurer or PBM failing to provide a step therapy exception. T.C.A. § 56-7-3502
- Allowing Disclosures: Insurer or PBM penalizing a pharmacy for (or restricting pharmacy from) disclosing a lower price available for a prescription drug by not using health insurance for prescription purchase. T.C.A. § 56-7-3114
- Other: Please describe below if your complaint does not fall into the above categories
Enhanced Dispensing Fee for Low-Volume Pharmacies
As part of 2022 Public Chapter 1070, pharmacies that meet low-volume thresholds per TennCare standards may qualify for the enhanced dispensing fee of $13.16 per prescription (current TennCare rate as of November 1, 2023)
- Eligibility: Fewer than 65,000 prescriptions annually.
- The pharmacy is required to certify this eligibility each year by December 1.
- Certification covers the July 1 – June 30 look-back period.
- TDCI confirm eligibility and notify PBMs.
Click here to download a template attestation document that you can fill out and submit to each PBM you work with. TPA has maintained an online directory below to assist pharmacies on where to submit your certification.
Quick Links & Forms
PBM Contact Directory
| ALLUMA | networkcompliance@express-scripts.com |
| AMWINS GROUP BENEFITS LLC | ProvRelContracting@elixirsolutions.com |
| ARCHIMEDES LLC | memberservices@archimedesrx.com |
| BENECARD SERVICES INC. | NetworkQuality@benecardpbf.com |
| CAPITAL RX INC. | Provider.Relations@cap-rx.com |
| CAREMARK L.L.C. | Qualtrics Survey | Qualtrics Experience Management |
| CENTENE PHARMACY SERVICES INC. | claimsprocessing@centene.com |
| CHANGE HEALTHCARE PHARMACY SOLUTIONS INC. | Provider.Relations@changehealthcare.com |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY | NetworkCompliance@express-scripts.com |
| CITIZEN’S RX LLC | providerrelations@citizensrx.com |
| DST PHARMACY SOLUTIONS INC. | rservice@dsthealth.com |
| ELIXIR RX SOLUTIONS LLC | ProvRelContracting@elixirsolutions.com |
| EMPLOYEE HEALTH INSURANCE MANAGEMENT INC. | rxreimbursements@ehimrx.com |
| ENVOLVE PHARMACY SOLUTIONS | claimsprocessing@centene.com |
| EPIPHANY RX LLC | pharmacynetwork@epiphanyrx.com |
| EXPRESS SCRIPTS LLC | Attestation Form to NetworkCompliance@express-scripts.com |
| HEALTHCARE HIGHWAYS RX LLC | providerrelations@hchrx.com |
| HUMANA PHARMACY SOLUTIONS INC. | PharmacyContractRequest@humana.com |
| INDEPENDENT HEALTH’S PHARMACY BENEFIT DIMENSIONS LLC | providerservice@servicing.independenthealth.com |
| INTEGRATED PRESCRIPTION MANAGEMENT INCORPORATED | pharmacycontracts@rxipm.com |
| KROGER PRESCRIPTION PLANS INC. | rxplans@kroger.com |
| MAGELLAN RX MANAGEMENT LLC | RxNetworksDept@magellanhealth.com |
| MAXCARE | pharmacynetworks@maxcarerx.com |
| MAXORPLUS LTD. | providerrelations@maxor.com |
| MEDIMPACT HEALTHCARE SYSTEMS INC. | PharmacyOperationsSups@medimpact.com |
| MEDONE | providerrelations@medone-rx.com |
| MERIDIANRX LLC | pharmacyservices@meridianrx.com |
| NAVITUS HEALTH SOLUTIONS LLC. | providerrelations@navitus.com |
| OPTUMRX INC. | provider.relations@optum.com |
| PERFORMRX LLC | pharmacynetworkcredentials@performrx.com |
| PHARMACY DATA MANAGEMENT INC. | pharmacyenrollment@pdmi.com |
| PHARMPIX | retailnetwork@pharmpix.com |
| PRESCRYPTIVE HEALTH INC. | pharmacyrelations@prescryptive.com |
| PRIME THERAPEUTICS LLC | PharmacyOps@primetherapeutics.com |
| PROACT INC. | updates@proactrx.com |
| PROCARE PHARMACY BENEFIT MANAGER INC. | network@procarerx.com |
| RXSENSE | pharmacynet@rxsense.com |
| SAV-RX | provider@savrx.com |
| SCRIPT CARE LTD. | providerinfo@scriptcare.com |
| SMITHRX | pharmacynetwork@smithrx.com |
| SOUTHERN SCRIPTS LLC | pharmacynetwork@southernscripts.net |
| VENTEGRA | network@ventegra.com |
| WELLDYNERX LLC | PharmacyInfo@welldyne.com |
FAQs
Q: Do I have to use the Standard Appeal Form?
Yes. PBMs are required to accept the TDCI-issued form.
Q: What documentation counts as “actual cost”?
Invoices, purchase orders, or wholesaler statements are acceptable.
Q: Can appeals apply to similarly situated pharmacies?
Yes. PBMs must correct reimbursements across similarly situated pharmacies.
Q: When should I file a complaint vs. an appeal?
- File an appeal for reimbursement disputes.
- File a complaint for systemic or policy violations (e.g., patient steering, network issues).
Q: What do I do if the claim is against a PBM contracted with a federal program?
- Submit to Medicare Complaint line to partd_monitoring@cms.hhs.gov
- Communicate with TPA in order to inform CMS Regional Office
Other Applicable PBM Laws in Tennessee
- Creation and oversight of the PBM process for state government programs (TCA Title 4)
- Prompt Pay Requirements (TCA 56-7-126)
- “Any Willing Pharmacy” Statute (TCA 56-7-2359)
- Patient Choice Statute (TCA 56-7-3120)
- Standards for PBM Identification Cards (TCA 56-7-2361)
- Audit and Recoupment Restrictions for Pharmacy Services (TCA 56-7-2362)
- Pharmacy Audit Bill of Rights and Restrictions on MAC Lists (TCA 56-7-3101 through TCA 56-7-3112)
- Licensure as Pharmacy Benefits Manager (Mandatory PBM Licensure) (TCA 56-7-3113)
- Right to Provide Information Regarding Amount of Insured’s Cost Share of Prescription Drug (Prohibition on PBM Gag Clauses) (TCA 56-7-3114)
- Prohibition on PBMs from Assessing Retroactive, Non-Transparent Fees on Pharmacists or Pharmacies (TCA 56-7-3115)
- Prohibition on PBMs from Requiring Pharmacists to Dispense Contrary to Professional Judgment (TCA 56-7-3116)
- Prohibition on PBMs for Utilizing Spread Pricing and Prohibition Against Below Cost Claims (TCA 56-7-3206)
- Disclosure of Material Changes to Contract Provisions (TCA 56-7-3117)
- Additional Contract Protections and Prohibited PBM Practices (TCA 56-7-3118)
- Discrimination Against 340B Entities (TCA 56-7-3119)
- Cost Calculations and Pharmacy Right to Disclose Costs to Patients (TCA 56-7-3201 through TCA 56-7-3204)
- Real Time Benefit Tool (TCA 56-7-3208)
- Audit and Recoupment Restrictions for Pharmacy Claims (TCA 56-32-138)
- PBM Authorization Statutes for TennCare (TCA 71-5-138, TCA 71-5-197, TCA 71-5-198)
These laws can also be accessed online in the Tennessee Code Annotated (TCA).