{"data":{"id":"us/42-cfr-423.124","jurisdiction":"us","citation":"42 CFR 423.124","heading":"Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies.","body":"(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—\n(i) Cannot reasonably be expected to obtain such drugs at a network pharmacy; and\n(ii) Do not access covered Part D drugs at an out-of-network pharmacy on a routine basis.\n(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.\n(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).\n(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.","path":["Title 42—Public Health","CHAPTER IV—CENTERS FOR MEDICARE \u0026 MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES","SUBCHAPTER B—MEDICARE PROGRAM","PART 423—VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT","Subpart C—Benefits and Beneficiary Protections"],"source_url":"https://www.ecfr.gov/api/versioner/v1/full/2026-08-25/title-42.xml","current_through":"2026-08-25","vintage":"","retrieved_at":"2026-08-27T02:26:11Z","sha256":"0cb7f7aa8c0f3246eb915879c5aca50ab760caee74ed88ad8465ca388a448fa3","source_id":"us-cfr","stale":true,"prev":"us/42-cfr-423.120","next":"us/42-cfr-423.128"},"notice":"GroundRules: Original legal text. Not legal advice."}