Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will findabbreviated 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 haveadequate access to covered prescription drugs. Access to covered drugs from an out-of-network pharmacyis required when enrollees: (1) cannot reasonably be expected to obtain such drugs at a network pharmacyand (2) do not access covered drugs at out-of-network pharmacies on a routine basis. A plan is required toestablish reasonable rules to appropriately limit out-of-network access to covered prescription drugs. 42CFR Sections 423.120(a) and 423.124; Medicare Prescription Drug Benefit Manual, Chapter 5, Section60.1.If a plan sponsor does not have all of the information it needs to make a decision, the plan sponsor should makereasonable and diligent efforts to obtain the missing information within the standard timeframe for making adecision and notifying the enrollee of the decision (i.e., within 72 hours after receiving the request or physician'sor other prescriber's supporting statement). When a plan sponsor could acquire missing information, such as aNational Drug Code (NDC) number, by contacting the enrollee's pharmacist, physician, or other prescriber, itshould 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 could issuea favorable decision within the 72-hour timeframe (the plan sponsor is not required to say how much thepayment will be in its notice to the enrollee), and utilize the remainder of the 30-day payment period describedin 40.2 and 130.1 of this chapter to determine how much the enrollee should be reimbursed and makepayment. If a plan sponsor chooses to send the payment within the 30-day timeframe after notifying the enrolleeof the favorable decision within the 72-hour timeframe, the initial notice to the enrollee must include thefollowing information: 1) the plan sponsor is approving the request; 2) payment will be sent within 30 days afterthe request was received; 3) if the enrollee does not agree with the amount received, he or she can request anappeal with the plan sponsor; and 4) briefly explain that the member may not receive the entire amount he orshe paid out-of-pocket because certain items (e.g., co-payment amounts) are not reimbursable, and include abrief summary of items that are generally subtracted. Prescription Drug Benefit Manual, Chapter 18, 30.3.2.The Plan will generally cover prescriptions only if they are filled at a Plan network pharmacy. Prescriptionsfilled at an out-of-network pharmacy may only be covered when a network pharmacy is not available. The Planwill typically cover prescriptions filled at an out-of-network pharmacy when the prescription is for a medicalemergency or urgent care, when there are no 24-hour network pharmacies within a reasonable driving distanceor when the prescription is for a drug that is out of stock at an accessible network pharmacy. If an enrollee mustuse an out-of-network pharmacy, the enrollee will generally have to pay the full cost when the prescription isfilled. The enrollee can ask the Plan to reimburse their share of the cost by submitting proof of payment with arequest for reimbursement. In some cases the enrollee will be responsible for the difference between what thePlan normally pays and what the out-of-network pharmacy charges the enrollee. Please refer to the Plan'sEvidence of Coverage.