42 CFR § 423.124 - Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies.
---
identifier: "/us/cfr/t42/s423.124"
source: "ecfr"
legal_status: "authoritative_unofficial"
title: "42 CFR § 423.124 - Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies."
title_number: 42
title_name: "Public Health"
section_number: "423.124"
section_name: "Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies."
chapter_name: "CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES"
subchapter_number: "B"
subchapter_name: "MEDICARE PROGRAM"
part_number: "423"
part_name: "VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT"
positive_law: false
currency: "2026-04-05"
last_updated: "2026-04-05"
format_version: "1.1.0"
generator: "[email protected]"
authority: "42 U.S.C. 1302, 1306, 1395w-101 through 1395w-152, and 1395hh."
regulatory_source: "70 FR 4525, Jan. 28, 2005, unless otherwise noted."
cfr_part: "423"
---
# 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) 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).
(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.