---
kind: "section"
citation: "42 C.F.R. § 423.124"
title: "42"
number: "423.124"
heading: "Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies."
url: "https://uscodex.org/cfr/42/423.124"
---

# §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)](#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)](/cfr/42/423.104.md?p=d-2-i-B) and [423.104(e)](/cfr/42/423.104.md?p=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.

## Notes

### Authority

Authority: 42 U.S.C. 1302, 1306, 1395w-101 through 1395w-152, and 1395hh.

### Source

Source: 70 FR 4525, Jan. 28, 2005, unless otherwise noted.