Last update: February 4, 2021
TennCare pharmacy benefits are managed by TennCare and administered by OptumRx, the TennCare pharmacy benefit manager (PBM). TennCare, in conjunction with OptumRx, manages the medication formulary, also known as the Preferred Drug List (PDL). The PDL classifies preferred and non-preferred typical and atypical antipsychotics. Prior authorization applies to atypical antipsychotic agents.
In an effort to assist prescribers and providers, TennCare allows prior authorization (PA) requirements to be bypassed for certain medications when specific medical conditions exist. Those specific medications, including atypical antipsychotics and their corresponding diagnoses, are noted in the TennCare Appropriate Diagnosis for Prior Authorization Bypass List. Prescribing preferred agents, when clinically appropriate, in conjunction with including an appropriate ICD-10 code on the prescription, should allow for authorization. This allows your patients to obtain clinically appropriate medications in a timely fashion, as well as promoting medication adherence.
TennCare and OptumRx update Optumrx.com/TennCare frequently with news and notifications about formulary status and clinical criteria changes. The TennCare Preferred Drug List and TennCare Appropriate Diagnosis for Prior Authorization Bypass List can also be found on this website.