CMS Pub. 100-18, ch. 12, § 20.8

PDPs cannot limit coverage to only mail order prescription drugs and must meet specific

standards in 42 CFR 423.120(a)(1) regarding the assembling of broad networks of retail

pharmacies to provide convenient access to beneficiaries. While waivers of the mail order-

only prohibition will not be granted, CMS also recognizes different circumstances

surrounding employer/union group health plan coverage as compared to other PDPs. For

example, an employer/union arrangement may have only a small number of Part D eligibles

concentrated in a local area within a large region. Employers/unions also have an interest in

ensuring their Part D eligibles have adequate pharmacy access.

To facilitate the offering of such plans and maximize flexibility, CMS has waived the specific

Part D retail pharmacy access standards contained in 423.120(a)(1) for “800 series” and Direct

Contract EGWPs as long as the PDP sponsor attests that its networks are and will continue to

be sufficient to meet the needs of its Part D eligibles, including situations involving

emergency access. However, CMS may review the adequacy of the pharmacy networks and

potentially require expanded access in the event of beneficiary complaints or for other reasons

in order to ensure that the plan’s network is sufficient to meet the needs of its enrollee

population.

Note that other than the waiver of the retail pharmacy access requirements described above,

no other waivers or modifications of the Part D pharmacy access requirements have been

granted for EGWPs. Thus, all PDP sponsors offering EGWPs must adhere to all other CMS

pharmacy access requirements (e.g., the requirements for long term care, home infusion, and

I/T/U pharmacy access). See 42 CFR 423.120(a) and chapter 5, section 50, of this manual.