A state of emergency and public health emergency has been declared in North Carolina, South Carolina, and Tennessee since Sept. 26, 2024, by President Biden and HHS Secretary Becerra. Existing guidance around these emergencies follows:
Out-of-network access: Part D sponsors are expected to apply out-of-network policies to facilitate access to medications during any federal disaster declaration or other public health emergency declaration in which Part D enrollees are evacuated or otherwise displaced from their place of residence and cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy.
In addition, in circumstances in which normal distribution channels are unavailable, Part D sponsors are expected to liberally apply their out-of-network policies to facilitate access to medications.
Refill-too-soon edits: Part D sponsors are expected by CMS to lift ‘refill-too-soon’ edits to facilitate access to medications. CMS expects that Part D sponsors will continue to lift these edits until the termination of a public health emergency or the end of a declared disaster or emergency.
CMS also expects Part D sponsors to allow an affected enrollee to obtain the maximum extended day supply, if requested and available at the time of refill. CMS expects that Part D sponsors will continue to lift these edits until the termination of a PHE or the end of a declared disaster or emergency.
In the case of a PHE, it terminates when it no longer exists or upon the expiration of the 90-day period beginning from the initial declaration, whichever occurs first.
We recommend contacting Part D sponsors directly for the most accurate and up-to-date information. They can provide specific details regarding plan coverage, including any exceptions or limitations.
Additional information on guidance from CMS can be found within Sections 50.12 and 60.1 of Chapter 5 of the Prescription Drug Benefit Manual.