Prescription drug: means a drug that under federal or state law is required to be dispensed only pursuant to a prescription order or is restricted to use by individuals authorized by law to prescribe drugs. See Tennessee Code 56-7-3201
Representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(1) A covered entity shall, upon request of an enrollee, enrollee’s healthcare provider, or authorized third party, furnish the cost, benefit, and coverage data described in subsection (b) to the enrollee, the enrollee’s healthcare provider, or an authorized third party, and shall ensure that the data is:
(A) Accurate as of the most recent change to the data that was made prior to the date of request;(B) Provided in real time; and(C) Provided in the same format in which the request is made.(2)(A) A request for coverage data must be in a format that uses established industry content and transport standards as published by the following:
(i) A standard developing organization that is accredited by the American National Standards Institute, including, but not limited to, the National Council for Prescription Drug Programs, ASC X12, and Health Level 7; or(ii) A relevant governing entity of this state or the federal government, including, but not limited to, the federal centers for medicare and medicaid services and the office of national coordinator for health information technology.(B) The following are not acceptable formats for requests for coverage data under this section:
(i) A facsimile; or(ii) Use of a proprietary payor or patient portal or other electronic form.(b) A covered entity that receives a request for data that complies with subsection (a) shall provide the following data for each drug covered under the enrollee’s health plan:
(1) The enrollee’s eligibility information for the drug;(2) A list of any clinically appropriate alternatives to drugs covered under the enrollee’s health plan;(3) Cost-sharing information for the drugs and the clinically appropriate alternatives; and(4) Applicable utilization management requirements for the drugs or clinically appropriate alternatives, including prior authorization, step therapy, quantity limits, and site-of-service restrictions.(c) A covered entity that furnishes data as provided in subsection (b) shall not:
(1) Restrict, prohibit, or otherwise hinder a healthcare provider from communicating or sharing with the enrollee or enrollee’s authorized representative:
(A) The data set forth in subsection (b);(B) Additional information on lower-cost or clinically appropriate alternative drugs, whether or not the drugs are covered under the enrollee’s plan; or(C) Additional payment or cost-sharing information that may reduce the patient’s out-of-pocket costs, such as cash price or patient assistance, and support programs sponsored by a manufacturer, foundation, or other entity;(2) Except as may be required by law, interfere with, prevent, or materially discourage access to, exchange of, or the use of the data set forth in subsection (b), including:
(A) Charging fees;(B) Failing to respond to a request at the time made when such a response is reasonably possible;(C) Implementing technology in nonstandard ways; or(D) Instituting requirements, processes, policies, procedures, or renewals that are likely to substantially increase the complexity or burden of accessing, exchanging, or using the data; or(3) Penalize a healthcare provider for:
(A) Disclosing the information described in subdivision (c)(1) to an enrollee; or(B) Prescribing, administering, or ordering a clinically appropriate or lower-cost alternative drug.
