Tennessee TN

TennCare is ~100% managed care (3 MCOs: Wellpoint/ex-Amerigroup, BlueCare/BCBST, UnitedHealthcare Community Plan). Medical PA is per-MCO; the state runs a thin but real authority layer. PHARMACY is carved out statewide to OptumRx (PBM) since Jan 1 2025 (previously CVS Caremark) — TennCare drug PA criteria, PDL, opioid criteria, and auto-exempt/attestation lists all live on OptumRx CDN (contenthub-aem.optumrx.com), surfaced via the state PBM page. State-level PA artifacts that DO exist: TennCare Rule 1200-13 (medical necessity), the Cost-Effective Alternative (CEA) Prior Authorization Form (state-published PDF), and MCO statewide contract. Medical clinical criteria themselves are per-MCO (Wellpoint/BlueCare/UHC provider portals). TWO state_meta URL pins are now DEAD 404: pa_index/provider_manuals=providers/manuals.html and pharmacy=providers/pharmacy.html. NOTE: prior pa_codes_master doc (id 302) is a State-EMPLOYEE benefit drug list (partnersforhealth / CVS Caremark via info.caremark.com/oe/stateoftn), NOT TennCare Medicaid — that pin is mislabeled. The correct TennCare Medicaid pharmacy criteria are the OptumRx PDFs ingested here.

Last award: 2021-11-08. Next due: next full RFP not yet announced; would be ~2030–2031 absent early re-procurement.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How TN requires PA Tennessee's Medicaid program, TennCare, mandates prior authorization (PA) for specific medications and services based on clinical necessity and cost-effectiveness. The requirements are detailed in various documents and regulations. For instance, the Opioid Medications for Acute and Chronic Use document specifies that acute opioid prescriptions up to a 15-day supply do not require PA unless they exceed 60 MME/day. Subsequent fills of 10 days or more require PA if certain criteria are met. Chronic opioid use is subject to stricter guidelines, requiring SBIRT (Screening, Brief Intervention, Referral to Treatment) and no active addiction, with a maximum daily dose of 60 MME. The Auto-Exempt and Attestation Drug List, effective May 2026, lists brand-name drugs that do not require prior authorization. These include analgesics, antibiotics, antivirals, and cardiovascular agents. For other medications, providers must refer to the Prior Authorization, Step Therapy, & Quantity Limit List available on OptumRx's website (https://info.caremark.com/oe/stateoftn) for specific requirements. The Cost-effective Alternative (CEA) Prior Authorization Form is used when a service not on the pre-approved list in Policy BEN 08-001 is requested. Providers must document that the proposed service is cost-effective compared to TennCare-covered services, medically appropriate, and prevents more costly future treatments. ## 2. How TN publishes and reports PA Tennessee publishes its PA requirements through various official documents and websites. The Auto-Exempt and Attestation Drug List and the Opioid Medications for Acute and Chronic Use document are available on the TennCare website (https://www.tn.gov/content/dam/tn/partnersforhealth/documents/). The Prior Authorization, Step Therapy, & Quantity Limit List is hosted by OptumRx at https://info.caremark.com/oe/stateoftn. Additionally, the Performance Drug List with Advanced Control Specialty Formulary and the Advanced Control Specialty Formulary Drug List are referenced for covered drugs. TennCare also maintains a thin but real authority layer through Rule 1200-13 and the CEA form, which providers must use for certain services not on the pre-approved list. The TennCare website provides links to these documents, ensuring that providers have access to the necessary information. ## 3. TN's CMS-0057-F and PA-reform compliance posture Tennessee's posture relative to CMS-0057-F is observed through its structured approach to managing PA processes, though no explicit CMS-0057-F compliance commitment appears in the source documents. The state lists medications requiring PA on the Prior Authorization, Step Therapy, & Quantity Limit List hosted by OptumRx, which is updated regularly and accessible online. The Auto-Exempt and Attestation Drug List, effective May 2026, provides clear guidelines for PA requirements. Specific criteria in documents like the Opioid Medications for Acute and Chronic Use document ensure that clinical necessity is a key factor in determining PA needs. **WISeR is not applicable to TN** — the CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model applies only to AZ, NJ, OH, OK, TX, and WA. Some documents (e.g. the CEA form) lack specific CPT/HCPCS codes or effective/revised dates, leaving gaps in the source record. ## 4. How TN runs its own program Tennessee's Medicaid program is primarily managed through a network of Managed Care Organizations (MCOs) and a carve-out for pharmacy services. The state has three MCOs: Wellpoint/ex-Amerigroup, BlueCare/BCBST, and UnitedHealthcare Community Plan. These MCOs handle medical PA on a per-MCO basis, while the state maintains a thin authority layer through Rule 1200-13 and the CEA form. Pharmacy services are carved out statewide to OptumRx (PBM) since January 1, 2025. This transition from CVS Caremark reflects Tennessee's efforts to streamline pharmacy management and ensure consistent PA processes across the state. The TennCare III 1115 waiver subsumes TennCare II and includes various provisions aimed at improving healthcare delivery and cost-effectiveness. The foster-care MCO program, TennCare Select/SelectKids, is another component of the state's managed care system, ensuring that children in foster care receive appropriate medical services. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Managed Care Dominance**: Tennessee's Medicaid program is heavily reliant on MCOs for most medical PA processes. - **Pharmacy Carve-Out**: Pharmacy services are managed by a single PBM (OptumRx) statewide, ensuring consistency in PA requirements. - **Structured Documentation**: The state provides detailed documents and lists to guide providers on PA requirements, including specific criteria for opioids and auto-exempt drugs. ### What's Missing/Uncertain: - **CMS-0057-F Compliance Details**: No explicit CMS-0057-F commitment in source documents; some forms lack CPT/HCPCS codes and effective/revised dates. - **Gold Card Law Details**: There is no specific information about a Tennessee gold card law in the source documents. - **Fiscal Agent History**: While there is a history of fiscal agent transitions (ACS-Inc → Conduent/Gainwell), more detailed information on the transition process and its impact on PA systems would be beneficial. Overall, Tennessee's Medicaid program demonstrates a structured approach to managing prior authorization processes through MCOs and a centralized pharmacy carve-out, with several gaps in the source record where additional clarity would help.