Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.  A Part D plan must have enough contracted retail pharmacies in its network to ensure that enrollees have adequate access to covered prescription drugs. Access to covered drugs from an out-of-network pharmacy is required when enrollees: (1) cannot reasonably be expected to obtain such drugs at a network pharmacy and (2) do not access covered drugs at out-of-network pharmacies on a routine basis. A plan is required to establish reasonable rules to appropriately limit out-of-network access to covered prescription drugs. 42 CFR Sections 423.120(a) and 423.124; Medicare Prescription Drug Benefit Manual, Chapter 5, Section 60.1.  Vaccines administered in a physician's office or by other non-network providers may be covered under the out-of-network access rules. A Part D enrollee may self-pay for the vaccine cost and its administration and submit a paper claim for reimbursement to his or her Part D sponsor. 42 CFR Section 423.124; Prescription Drug Benefit Manual, Chapter 5, Section 60.3.4.  If a plan sponsor does not have all of the information it needs to make a decision, the plan sponsor shouldmake reasonable and diligent efforts to obtain the missing information within the standard timeframe formaking a decision and notifying the enrollee of the decision (i.e., within 72 hours after receiving therequest or physician's or other prescriber's supporting statement). When a plan sponsor could acquiremissing information, such as a National Drug Code (NDC) number, by contacting the enrollee's pharmacist,physician, or other prescriber, it should do so instead of relying on the enrollee to provide the information.Prescription Drug Benefit Manual, Chapter 18, ?30.3.2.  Occasionally, a plan sponsor will have enough information to determine that a reimbursement request ispayable, but not enough to determine the exact amount. When this situation occurs, the plan sponsor couldissue a favorable decision within the 72-hour timeframe (the plan sponsor is not required to say how muchthe payment will be in its notice to the enrollee), and utilize the remainder of the 30-day payment perioddescribed in ??40.2 and 130.1 of this chapter to determine how much the enrollee should be reimbursedand make payment. If a plan sponsor chooses to send the payment within the 30-day timeframe afternotifying the enrollee of the favorable decision within the 72-hour timeframe, the initial notice to theenrollee must include the following information: 1) the plan sponsor is approving the request; 2) paymentwill be sent within 30 days after the request was received; 3) if the enrollee does not agree with the amountreceived, he or she can request an appeal with the plan sponsor; and 4) briefly explain that the member maynot receive the entire amount he or she paid out-of-pocket because certain items (e.g., co-paymentamounts) are not reimbursable, and include a brief summary of items that are generally subtracted.Prescription Drug Benefit Manual, Chapter 18, ?30.3.2.  The Part D Plan covers a number of vaccines (including vaccine administration) under the Part D benefit.The Plan's coverage of a vaccine depends on the type of vaccine, where the enrollee gets the vaccine andwho administers the vaccine. Note that in some cases, an enrollee may receive a vaccine outside of thePlan's pharmacy network, and may have to pay for the entire cost of the vaccine and its administration. Theenrollee can then ask the Plan to pay its share of the vaccine costs. For detailed information on howvaccines are reimbursed, please refer to the Plan's Evidence of Coverage (EOC).