(a) When a patient’s out-of-pocket cost for a prescription or covered service is percentage-based, the covered entity or pharmacy benefits manager shall calculate the out-of-pocket cost such that when the out-of-pocket cost is added to the amount that the covered entity or pharmacy benefits manager will directly pay to the pharmacy or other dispenser the sum will equal the actual reimbursement.

Terms Used In Tennessee Code 56-7-3202

  • Actual reimbursement: means the total amount that a covered entity or pharmacy benefits manager determines that a pharmacy or other dispenser will receive consistent with the provider agreement, and is the sum of the amount the covered entity or pharmacy benefits manager will pay directly to the pharmacy or other dispenser plus any applicable patient out-of-pocket cost paid directly by the patient to the pharmacy or other dispenser, for dispensing of a particular prescription or providing a covered service. See Tennessee Code 56-7-3201
  • Covered entity: means a covered entity as defined in §. See Tennessee Code 56-7-3201
  • Pharmacy benefits manager: means a pharmacy benefits manager as defined in §. See Tennessee Code 56-7-3201
  • Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
(b) The requirements of subsection (a) shall not apply when patient out-of-pocket cost for a prescription or covered service is percentage-based for only a specified portion or predefined subset of drug tiers or specialty drug categories and the remainder of the covered drug prescriptions or services available to the patient are associated with predefined and specific out-of-pocket costs.
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