CMS Pub. 100-16, ch. 4, § 10.12.2

MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and

manufacturers, as long as the following conditions are met (42 CFR 422.100(l)):

• The MA plan provides all categories of DME covered under original Medicare Part

B;

• The MA plan ensures that enrollees have access to all medically necessary (including

non-preferred) DME products or brands;

• The MA plan’s contracted suppliers provide access to all preferred DME brands;

• During an enrollee’s first year of enrollment in an MA plan, if the enrollee requests,

the plan will provide a 90-day transition period (commencing with the initial time of

enrollment) during which the plan provides (and repairs, as applicable) non-preferred

DME brands furnished in the previous year;

• Although the MA plan may add brands to its preferred formulary during the year, it

may not remove any brands mid-year;

• The MA plan treats denials of non-preferred DME products or brands as organization

determinations;

• The MA plan discloses DME coverage limitations and appeal rights in the case of a

denial of a non-preferred DME product or brand with the EOC and ANOC and on its

website; and

• The MA plan provides full coverage, without limitation on brand and manufacturer,

to DME categories or subcategories annually determined by CMS to require full

coverage.