Rev: November 6, 2017 1

TennCare Pharmacy Program c/o Magellan Health Services

11013 West Broad Street, Suite 500 Glen Allen, Virginia 23060

Do you need special help? Call 1-800-878-3192 for free. Versión en español atrás.

PBM 3 NCov Handout.7

Rev: November 6, 2017

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 2005-5 (6/1/05); State Plan Amendment

TN 2005-015 (effective 1/1/06); TCA 71-5-102 (d); Tenn.Comp.R.&Regs. 1200-13-13-.04, 1200-13-13-.10,

1200-13-14-.04, 1200-13-14-.10]

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.

Rev: November 6, 2017 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.

Rev: November 6, 2017 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 000593

Nashville, TN 37202-0593

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 1-800-878-3192.

2. Or fax. You can fax your appeal page or letter for free to 1-888-345-5575.

3. Or call. You can call TennCare for free at 1-800-878-3192.

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

1-800-878-3192. 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.

Rev: November 6, 2017 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 1-800-878-3192.

Do you have a mental illness and need help with this letter? The TennCare Advocacy Program can

help you. Call them for free at 1-800-758-1638.

If you have a hearing or speech problem, you can call TennCare on a TTY/TDD machine. Our

TTY/TDD number is 1-866-771-7043.

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 1-800-878-3192.

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 1-866-311-4287. In Nashville, call 615-743-2000.

TN A003.15

Rev: November 6, 2017

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 1-855-259-0701.

Do you have a hearing or speech problem and have questions or need help?

Call the Tennessee Relay Service (TNRS) at 1-800-848-0298. Ask them to connect you

with the Tennessee Health Connection at 1-855-259-0701.

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

1-800-878-3192.

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

1-877-801-0044.

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 1-800-758-1638.

Then, if you still need help, call the TennCare Solutions Unit at 1-800-878-3192.

TN A003.15

Rev: November 6, 2017

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 1-855-259-0701.

We can connect you with the free help or service you

need. (For TTY call: 1-800-848-0298)

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 email, 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 37243

Email: HCFA.Fairtreatment@tn.gov

Phone: 1-855-857-1673 (TRS 711)

You can get a complaint form online at:

http://www.tn.gov/assets/entities/tenncare/attachments/complaintform.pdf

U.S. Department of Health & Human Services Office for Civil Rights

200 Independence Ave SW, Rm 509F, HHH Bldg

Washington, DC 20201

Phone: 1-800-368-1019

(TDD): 1-800-537-7697

You can get a complaint form online at:

http://www.hhs.gov/ocr/office/file/index.html

Or you can file a complaint online at:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

TN A014.6

Rev: November 6, 2017

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 1-855-259-0701 (TTY: 1-800-848-0298).

Kurdish: کوردی

1-855-بە پەیوەندی. بەردەستە تۆ بۆ بەخۆڕایی، زمان، یارمەتی خزمەتگوزاریەکانی دەکەیت، قەسە کوردی زمانی بە ئەگەر: ئاگاداری

259-0701 (TTY (1-800-848-0298 بکە.

Arabic: العربية

برقم اتصل. بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا: ملحوظة

(.0298-848-800-1)رقم هاتف الصم والبكم : 855-259-0701 -1

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 1-855-259-0701

（TTY 1-800-848-0298）。

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 1-855-

259-0701 (TTY: 1-800-848-0298).

Korean: 한국어

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-855-259-0701 (TTY: 1-800-848-0298)번으로 전화해 주십시오.

French: Français

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-855-259-0701 (ATS: 1-800-848-0298).

Amharic: አማርኛ

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-855-259-0701 (መስማት ለተሳናቸው: 1-800-848-0298).

Gujarati: ગજુરાતી સચુના: જો તમે ગજુરાતી બોલતા હો, તો નન:શલુ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-855-259-0701 (TTY: 1-800-848-0298).

Laotian: ພາສາລາວ

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ

ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-855-259-0701 (TTY: 1-800-848-0298).

TN A014.6

Rev: November 6, 2017

German: Deutsch

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur

Verfügung. Rufnummer: 1-855-259-0701 (TTY: 1-800-848-0298).

Tagalog: Tagalog

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika

nang walang bayad. Tumawag sa 1-855-259-0701 (TTY: 1-800-848-0298).

Hindi: ह िंदी ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-855-259-0701

(TTY: 1-800-848-0298) पर कॉल करें।

Serbo-Croatian: Srpsko-hrvatski

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.

Nazovite 1-855-259-0701 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom:

1-800-848-0298).

Russian: Русский

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 1-855-259-0701 (телетайп: 1-800-848-0298).

Nepali: नेपाली ध्यान हदन ुोस:् तपार्इंले नेपाली बोल्नु ुन्छ भने तपार्इंको ननम्तत भाषा स ायता सेवा रू ननिःशुल्क रूपमा उपलब्ध

छ । फोन गनु ुोस ् 1-855-259-0701 (हिहिवार्इ: 1-800-848-0298) ।

Persian: فارسی

ی م فراهم شمای برا گانیرا بصورتی زبان التیتسه د،یکنی م گفتگو فارسی زبان به اگر: توجه .دیریبگ تماس (TTY: 1-800-848-0298) 0701-259-855-1 با. باشد