WHAT SERVICES ARE COVERED BY TENNCARE?
Below are some of the services covered by TennCare. For a complete list of TennCare benefits and limits, visit the benefits page of the TennCare website.
Specialists: A specialist is a doctor who gives care for a certain illness or part of the body. One kind of specialist is a cardiologist, who is a heart doctor. Another kind of specialist is called an oncologist, who treats cancer. There are many kinds of specialists. Your PCP may send you to a specialist for care. This is called a referral. If your PCP wants you to go to a specialist, he or she will set up the appointment with the specialist for you.
Wellness and Preventive Care: TennCare covers most medical services necessary for physical and mental health, including hospital, physician, and pharmacy services. If you are having problems getting the medical care you need and want help working with your health plan call us at 1-800-758-1638.
Dental: TennCare only covers dental care for children under the age of 21. TennCare’s dental health plan is called Dentaquest. Their phone number is 1.855.418.1622.
TennCare does not cover any dental care, including oral surgery, for adults age 21 and older. For more information go to your TennCare member handbook.
Mental Health: Mental health services include physician and facility or residential treatment, mental health case management, and substance abuse treatment services. For more information, call your health plan. If you still need help, call us at 1-800-758-1638, Monday – Friday 8am – 5pm Central Time.
Transportation: If you don’t have a way to get to your health care visits, you may be able to get a ride from TennCare. If you need a ride to your health care visits, call your health plan. Try to call at least one week before your health care visit to make sure that you can get a ride. If you change times or cancel your health care visit, you must change or cancel your ride too.
You can get help with a ride:
• only for services covered by TennCare, and
• only if you don’t have any other way to get there.
If you are a child under the age of 21, you can have someone ride with you.
For the most up-to-date information about transportation, call your health plan. The number for your health plan is on the back of your TennCare card.
Children’s Health Care: Tennessee has made a commitment to promoting good health in children from birth until age 21. It's called the TennCare Kids program. TennCare Kids is a full program of checkups and health care services for children who have TennCare. These services make sure that babies, children, teens, and young adults receive the health care they need. Good health begins at birth, so it's important to Check In, Check Up and Check Back!
TennCare Pharmacy Benefit: Most pharmacies have contracts with TennCare. You may also look in your member handbook to see which pharmacies you can go to, or you can call your pharmacy health plan at 1-888-816-1680.
Prescription Drugs: Most, but not all, TennCare members have a prescription benefit. To find out if you have TennCare prescription benefits, go to your TennCare member handbook or call us at 1-800-758-1638.
For members with TennCare Prescription Benefits:
Preferred Drug List: TennCare has a list of medications called a Preferred Drug List or PDL. This is sometimes called a formulary. TennCare’s PDL lists the medications that TennCare pays for, as well as the rules and limitations necessary to meet medical necessity criteria. This list can change. Click here to see the current Preferred Drug List.
Prior Authorization: Some medications need a prior authorization (PA), or TennCare’s OK, even if they are listed on the PDL. Most doctors know about the PA process and will work with Magellan Health Services (TennCare’s pharmacy health plan) to request an OK. But, sometimes your prescription may be denied because your doctor didn’t request an OK, or the PA has not been processed yet, or Magellan Health Services denied the PA. If your prescription has been denied, call TennCare Advocacy for help at 1-800-758-1638, Monday – Friday 8am – 5pm Central Time.
Pharmacy Benefit Limits: Children with TennCare pharmacy benefits have no pharmacy limit. But, for most adults with TennCare pharmacy benefits, TennCare only pays for 5 prescriptions or refills each month. Only 2 of the 5 prescriptions can be brand name drugs. At least 3 must be generic. A generic works the same as a brand name drug, but usually costs less. What if you need more than limits allow? TennCare has an Over the Limit list and an Exempt list that may help you.
Over the Limit List of Drugs: The Over the Limit List (also called the Provider Attestation List) is a list of drugs you can get after you’ve reached your prescription limit if your doctor gets TennCare’s OK. To find out more about this list, click here.
The Exempt List of Drugs: The Exempt List (also called the Automatic Exemption List) is a list of drugs that will not count against the prescription limit. To find out more about this list, click here.