The Bureau of TennCare today provided TPA with the following update regarding the 2013-2014 Flu Season. The notice is also available as a stand-alone document here.
From the Bureau of TennCare
January 17, 2014
TennCare Update Regarding the 2013-2014 Flu Season
TennCare’s primary strategy for influenza management is prevention through vaccination programs. The Advisory Committee on Immunization Practices (ACIP) recommends annual vaccination of all persons aged 6 months and older. Vaccination should continue to be offered throughout the influenza season. Children aged 6 months through 8 years require 2 doses of influenza vaccine (administered a minimum of 4 weeks apart) during their first season of vaccination to optimize immune response.
Seasonal influenza vaccine will be covered by TennCare for all members under the medical and pharmacy benefits. The seasonal influenza vaccine is listed on the TennCare Auto-Exemption list; therefore it will not count toward an adult member’s monthly prescription limits.
Antiviral treatments such as Tamiflu® and Relenza®, should be reserved for use as an adjunct to vaccination. Both Tamiflu® and Relenza®, require Prior Authorization (see exceptions to the PA requirement below). In order to ensure appropriate use of the antiviral medications, the following clinical criteria and quantity limits will need to be met.
Tamiflu® and Relenza® will be approved if any of the following criteria are met:
- Member has been clinically diagnosed with influenza A, B or H1N1 AND drug therapy will be initiated within 48 hours of the onset of symptoms. (For individuals at high risk of influenza complications, approvals may be granted outside the initial 48 hours.)
- Member requires prophylaxis for influenza due to having been in close contact with an individual known to have influenza A, B or H1N1.
- Member has a suspected case of avian influenza (optimal doses and duration of treatment are not known, but will be dealt with case by case if necessary).
The following high risk populations are currently exempt from the PA requirement*:
- For Tamiflu®: children under 12 years of age, adults aged 60 years and older, and pregnant women (identified by use of prenatal vitamins).
- For Relenza®: adults aged 65 years and older and pregnant women (identified by use of prenatal vitamins).
- Up to 2 courses of therapy will be allowed per recipeint every 6 months:
- Tamiflu®: 20 tabs or 100mL per 180 days
- Relenza®: 40 blisters (2 inhalers) per 180 days
Process for Requesting Prior Authorization for patients who are not exempt from PA requirement:
TennCare recommends that all requests for prior authorization of Tamiflu and Relenza to be phoned in to the Magellan Call Center at: 866-434-5524 (Requests may be faxed in to 866-434-5523; however, it may take up to 24 hours to process faxed PA requests. Given the importance of beginning therapy as quickly as possible, this may not be a good option for patients.)
In situations in which prior authorization was not obtained by the prescriber, a pharmacist may be able to obtain authorization by contacting the call center at: 1-866-434-5524 if the prescriber included diagnostic information on the hardcopy prescription (e.g. ICD-9/10 code) or provides such information over the phone to the pharmacist.
* Please note that the exemptions are subject to change due to seasonal demand.