TennCare

Plain English Breakdown

Checked against official source text during the last sync.

Law to Cover HIV Drugs in TennCare

This bill adds long-acting injectable drugs for treating and preventing HIV to the list of medical services covered by TennCare.

What This Bill Does

• Adds long-acting injectable drugs used to treat or prevent HIV to the list of medical services that TennCare covers.
• Requires managed care organizations (MCOs) and pharmacy benefits managers (PBMs) to pay for these HIV drugs when given in a pharmacy, doctor's office, clinic, surgery center, or hospital.
• Ensures MCOs and PBMs cover claims for these drugs as both medical services and pharmacy benefits.
• Limits reimbursement so that providers can only be paid once per treatment under either the medical benefit or pharmacy benefit.

Who It Names or Affects

• People enrolled in TennCare who need long-acting injectable HIV drugs.
• Managed care organizations (MCOs) and pharmacy benefits managers (PBMs) contracted with TennCare to provide services.
• Healthcare providers who administer these HIV drugs.

Terms To Know

TennCare

The state's Medicaid program that provides health care coverage for low-income and disabled individuals.

Managed Care Organization (MCO)

A company that contracts with TennCare to provide medical services to its members.

Pharmacy Benefits Manager (PBM)

An organization that manages prescription drug benefits for insurance companies or government programs like TennCare.

Limits and Unknowns

• The bill only applies to MCOs and PBMs contracted with the bureau of TennCare.
• It is not clear how much this will cost or who will pay for it beyond the current year's budget allocations.

Official Summary Text

Present law requires m
edical assistance, including demonstration projects and programs designed to enhance the efficient and economic operation of
TennCare
,
to
be provided to those classes of individuals determined to be eligible
. Present law provides a list of services that may be deemed medical assistance. This bill adds to such list l
ong-acting injectable drugs intended for treatment and prevention of
HIV
and administered in a pharmacy, physician's office, clinic, ambulatory surgical treatment center,
or hospital
.

Additionally, this bill requires

a
managed care organization (MCO) or pharmacy benefits manager (PBM)
to
reimburse a claim for a long-acting injectable drug
(i) i
ntended for treatment and prevention of HIV and

(
ii
)
a
dministered in a pharmacy, physician's office, clinic, ambulatory surgical treatment center, or hospital.

An MCO or PBM that covers
such
a claim as a medical benefit or service
must
also cover any such claim as a pharmacy benefit
. However, the
MCO or PBM
must
only reimburse a provider for eac
h individual treatment or service provided
,
and
a
n individual provider may only be reimbursed for each claim under either the pharmacy benefit or the medical benefit or service.

This bill
applies to an MCO or PBM that is contracted with the bureau of TennCare to administer and provide or reimburse for medical or pharmacy services for TennCare enrollees on behalf of the bureau.

Current Bill Text

HOUSE BILL 2457
By Harris

SENATE BILL 2499
By Kyle
SB2499
012670
- 1 -

AN ACT to amend Tennessee Code Annotated, Title 4;
Title 56 and Title 71, relative to the coverage of
long-acting injectable drugs for the treatment or
prevention of human immunodeficiency virus.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
SECTION 1. Tennessee Code Annotated, Section 71-5-107(a), is amended by adding
the following as a new subdivision:
( ) Long-acting injectable drugs intended for treatment and prevention of human
immunodeficiency virus (HIV) and administered in a pharmacy, physician's office, clinic,
ambulatory surgical treatment center, or hospital, in accordance with § 71-5-175;
SECTION 2. Tennessee Code Annotated, Title 71, Chapter 5, Part 1, is amended by
adding the following as a new section:
71-5-175.
(a) A managed care organization (MCO) or pharmacy benefits manager (PBM)
shall reimburse a claim for a long-acting injectable drug:
(1) Intended for treatment and prevention of human immunodeficiency
virus (HIV); and
(2) Administered in a pharmacy, physician's office, clinic, ambulatory
surgical treatment center, or hospital.
(b) An MCO or PBM that covers a claim pursuant to subsection (a) as a medical
benefit or service shall also cover any such claim as a pharmacy benefit; provided, that:
(1) The MCO or PBM shall only reimburse a provider for each individual
treatment or service provided; and

- 2 - 012670

(2) An individual provider may only be reimbursed for each claim under
either the pharmacy benefit or the medical benefit or service.
(c) This section applies to an MCO or PBM that is contracted with the bureau of
TennCare to administer and provide or reimburse for medical or pharmacy services for
TennCare enrollees on behalf of the bureau.
SECTION 3. This act takes effect July 1, 2026, the public welfare requiring it.