When must a Part D drug plan fill a prescription at an out-of-network pharmacy?
Part D plans must ensure that their plan members have access to prescription drugs, under certain conditions, when they are outside of the plan’s service area. The Medicare Prescription Drug Benefit Manual details those conditions and offers several examples of situations in which plans should cover drugs dispensed at out-of-network pharmacies. See the excerpt below. Medicare Prescription Drug Benefit Manual (CMS Pub. No. 100-18), Chapter 5, Section 60.1, Out of Network Pharmacy Access: Part D sponsors must ensure that their enrollees have adequate access to covered Part D drugs dispensed at OON pharmacies when those enrollees cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy, and when such access is not routine. The coverage rules applicable to covered Part D drugs dispensed at OON pharmacies may generally mirror those applicable to covered Part D drugs dispensed at network pharmacies, to the extent that the OON pharmacy has the ability to effectuate t
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