TN Insurance Bulletin 23-05: Wholesaler Information Collected pursuant to Tenn. Comp. R. & Regs. 0780-01-95-.03

tn.gov/commerce STATE OF TENNESSEE DEPARTMENT OF COMMERCE AND INSURANCE 500 JAMES ROBERTSON PARKWAY NASHVILLE, TENNESSEE 37243-5065 615-741-6007 BILL LEE CARTER LAWRENCE GOVERNOR COMMISSIONER BULLETIN 23-05 To: Tennessee-Licensed Pharmacy Benefit Managers, Pharmacies, and Covered Entities From: Carter Lawrence, Commissioner Date: September 12, 2023 Re: Wholesaler Information Collected pursuant to Tenn. Comp. R. & Regs. 0780- 01-95-.03 The Tennessee Department of Commerce and Insurance (the “Department”) issues this bulletin to address concerns regarding the submission of wholesaler information by a pharmacy to a pharmacy benefit manager (“PBM”) as part of the pharmacy’s claim for reimbursement, as further detailed in Tenn. Comp. R. & Regs. 0780-01-95-.03. Tenn. Code Ann. § 56-7-3206(c)(3)(A)(vi) requires PBMs to apply the findings of an appeal in which a pharmacy prevails to all similarly situated pharmacies, as defined in Tenn. Code Ann. § 56-7-3206(c)(3)(C). However, a PBM cannot determine whether a nonappealing pharmacy qualifies as a similarly situated pharmacy unless the PBM reviewing the appeal knows, in addition to the elements in Tenn. Code Ann. § 56-7-3206(c)(3)(C)(i) and (iii), the wholesaler for each prescription drug or device for which the PBM processes a claim for reimbursement, regardless of whether the claim results in an appeal. This is why it is imperative pharmacies ensure PBMs know the wholesaler associated with each reimbursement claim as outlined in Tenn. Comp. R. Regs. 0780-01-95-.03(2)(k). Related to this requirement, stakeholders have raised that the National Council for Prescription Drug Programs (“NCPDP”) standards used by all pharmacies as part of the claims-submission process do not have a standard field where pharmacies can enter wholesaler information when submitting claims to a PBM and that the fields cannot be repurposed. However, Tenn. Comp. R. Regs. 0780-01-95-.03(2)(k) does not require PBMs to request the information in the NCPDP fields. Rather, it requires “[a] PBM [to] request this information as part of its processing of claims for reimbursement.” The Department issues this bulletin to remind PBMs of this obligation to ensure that wholesaler information is submitted to a PBM each time a pharmacy files a claim for reimbursement. The rules are not currently prescriptive as to how a PBM must request this information, as the Department believes that each PBM is best situated to determine how this requirement should be implemented in its own claims process. It is the Department’s position that Carter Lawrence (Sep 12, 2023 13:17 CDT) Bulletin 23-05 Page 2 tn.gov/commerce failure to request this information, which is an integral part of carrying out the requirements of Tenn. Code Ann. § 56-7-3206(c)(3)(A)(vi), as part of processing of claims for reimbursement is a violation of Tenn. Comp. R. Regs. 0780-01-95-.03(2)(k) subject to the penalties set out in Tenn. Code Ann. § 56-2-305. Any questions regarding the collection of wholesaler information should be directed to PBM.Compliance@tn.gov.