42 CFR 423.124 - Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies.

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There are 4 Updates appearing in the Federal Register for 42 CFR Part 423. View below or at eCFR (GPOAccess)
§ 423.124 Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies.
(a) Out-of-network access to covered part D drugs—
(1) Out-of-network pharmacy access. A Part D sponsor must ensure that Part D enrollees have adequate access to covered Part D drugs dispensed at out-of-network pharmacies when the enrollees—
(i) Cannot reasonably be expected to obtain such drugs at a network pharmacy; and
(ii) Do not access covered Part D drugs at an out-of-network pharmacy on a routine basis.
(2) Physician's office access. A Part D sponsor must ensure that Part D enrollees have adequate access to vaccines and other covered Part D drugs appropriately dispensed and administered by a physician in a physician's office.
(b) Financial responsibility for out-of-network access to covered Part D drugs. A Part D sponsor that provides its Part D enrollees with coverage other than defined standard coverage may require its Part D enrollees accessing covered Part D drugs as provided in paragraph (a) of this section to assume financial responsibility for any differential between the out-of-network pharmacy's (or provider's) usual and customary price and the Part D sponsor's plan allowance, consistent with the requirements of §§ 423.104(d)(2)(i)(B) and 423.104(e).
(c) Limits on out-of-network access to covered Part D. A Part D sponsor must establish reasonable rules to appropriately limit out-of-network access to covered Part D drugs.

Title 42 published on 2014-10-01.

The following are only the Rules published in the Federal Register after the published date of Title 42.

For a complete list of all Rules, Proposed Rules, and Notices view the Rulemaking tab.

  • 2015-05-06; vol. 80 # 87 - Wednesday, May 6, 2015
    1. 80 FR 25958 - Medicare Program; Changes to the Requirements for Part D Prescribers
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Interim final rule with comment period.
      Effective date: These regulations are effective on June 1, 2015. Applicability date: The provisions at § 423.120(c)(6) are applicable January 1, 2016. Comment date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on July 6, 2015.
      42 CFR Part 423

Title 42 published on 2014-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 423 after this date.

  • 2015-05-06; vol. 80 # 87 - Wednesday, May 6, 2015
    1. 80 FR 25958 - Medicare Program; Changes to the Requirements for Part D Prescribers
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Interim final rule with comment period.
      Effective date: These regulations are effective on June 1, 2015. Applicability date: The provisions at § 423.120(c)(6) are applicable January 1, 2016. Comment date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on July 6, 2015.
      42 CFR Part 423