[Code of Federal Regulations] [Title 42, Volume 3] [Revised as of October 1, 2006] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR423.128] [Page 369-371] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 423_VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT--Table of Contents Subpart C_Benefits and Beneficiary Protections Sec. 423.128 Dissemination of Part D plan information. (a) Detailed description. A Part D sponsor must disclose the information specified in paragraph (b) of this section in the manner specified by CMS-- (1) To each enrollee of a Part D plan offered by the Part D sponsor under this part; (2) In a clear, accurate, and standardized form; and (3) At the time of enrollment and at least annually thereafter. (b) Content of Part D plan description. The Part D plan description must include the following information about the qualified prescription drug coverage offered under the Part D plan-- (1) Service area. The plan's service area. (2) Benefits. The benefits offered under the plan, including- (i) Applicable conditions and limitations. (ii) Premiums. (iii) Cost-sharing (such as copayments, deductibles, and coinsurance), and cost-sharing for subsidy eligible individuals. (iv) Any other conditions associated with receipt or use of benefits. (3) Cost-sharing. A description of how a Part D eligible individual may obtain more information on cost-sharing requirements, including tiered or other copayment levels applicable to each drug (or class of drugs), in accordance with paragraph (d) of this section. (4) Formulary. Information about the plan's formulary, including- (i) A list of drugs included on the plan's formulary; (ii) The manner in which the formulary (including any tiered formulary structure and utilization management procedures used) functions; (iii) The process for obtaining an exception to a plan's formulary or tiered cost-sharing structure; and (iv) A description of how a Part D eligible individual may obtain additional information on the formulary, in accordance with paragraph (d) of this section. (5) Access. The number, mix, and distribution (addresses) of network pharmacies from which enrollees may reasonably be expected to obtain covered [[Page 370]] Part D drugs and how the Part D sponsor meets the requirements of Sec. 423.120(a)(1) for access to covered Part D drugs; (6) Out-of-network coverage. Provisions for access to covered Part D drugs at out-of-network pharmacies, consistent with Sec. 423.124(a). (7) Grievance, coverage determinations, and appeals procedures. All grievance, reconsideration, exceptions, coverage determination, reconsideration, exceptions, and appeal rights and procedures required under Sec. 423.564 et. seq. (8) Quality assurance policies and procedures. A description of the quality assurance policies and procedures required under Sec. 423.153(c), as well as the medication therapy management program required under Sec. 423.153(d). (9) Disenrollment rights and responsibilities. (10) Potential for contract termination. The fact that a Part D sponsor may terminate or refuse to renew its contract, or reduce the service area included in its contract, and the effect that any of those actions may have on individuals enrolled in a Part D plan; (c) Disclosure upon request of general coverage information, utilization, and grievance information. Upon request of a Part D eligible individual, a Part D sponsor must provide the following information-- (1) General coverage information. General coverage information, including-- (i) Enrollment procedures. Information and instructions on how to exercise election options under this part; (ii) Rights. A general description of procedural rights (including grievance, coverage determination, reconsideration, exceptions, and appeals procedures) under this part; (iii) Benefits. (A) Covered services under the Part D plan; (B) Any beneficiary cost-sharing, such as deductibles, coinsurance, and copayment amounts, including cost-sharing for subsidy eligible individuals; (C) Any maximum limitations on out-of-pocket expenses; (D) The extent to which an enrollee may obtain benefits from out-of- network providers; (E) The types of pharmacies that participate in the Part D plan's network and the extent to which an enrollee may select among those pharmacies; and (F) The Part D plan's out-of-network pharmacy access policy. (iv) Premiums; (v) The Part D plan's formulary; (vi) The Part D plan's service area; and (vii) Quality and performance indicators for benefits under the Part D plan as determined by CMS. (2) The procedures the Part D sponsor uses to control utilization of services and expenditures. (3) The number of disputes, and the disposition in the aggregate, in a manner and form described by CMS. These disputes are categorized as-- (i) Grievances according to Sec. 423.564; (ii) Appeals according to Sec. 423.580 et. seq.; and (iii) Exceptions according to Sec. 423.578. (4) Financial condition of the Part D sponsor, including the most recently audited information regarding, at a minimum, a description of the financial condition of the Part D sponsor offering the Part D plan. (d) Provision of specific information. Each Part D sponsor offering qualified prescription drug coverage under a Part D plan must have mechanisms for providing specific information on a timely basis to current and prospective enrollees upon request. These mechanisms must include-- (1) A toll-free customer call center that-- (i) Is open during usual business hours. (ii) Provides customer telephone service, including to pharmacists, in accordance with standard business practices. (2) An Internet website that-- (i) Includes, at a minimum, the information required in paragraph (b) of this section. (ii) Includes a current formulary for its Part D plan, updated at least monthly. (iii) Provides current and prospective Part D enrollees with at least 60 days notice regarding the removal or change in the preferred or tiered cost-sharing status of a Part D drug on its Part D plan's formulary. (3) The provision of information in writing, upon request. [[Page 371]] (e) Claims information. A Part D sponsor must furnish directly to enrollees, in the manner specified by CMS and in a form easily understandable to such enrollees, a written explanation of benefits when prescription drug benefits are provided under qualified prescription drug coverage. The explanation of benefits must-- (1) List the item or service for which payment was made and the amount of the payment for each item or service. (2) Include a notice of the individual's right to request an itemized statement. (3) Include the cumulative, year-to-date total amount of benefits provided, in relation to-- (i) The deductible for the current year. (ii) The initial coverage limit for the current year. (iii) The annual out-of-pocket threshold for the current year. (4) Include the cumulative, year-to-date total of incurred costs to the extent practicable. (5) Include any applicable formulary changes for which Part D plans are required to provide notice as described in Sec. 423.120(b)(5). (6) Be provided during any month when prescription drug benefits are provided under this part, including for covered Part D spending between the initial coverage limit described in Sec. 423.104(d)(3) and the out- of-pocket threshold described in Sec. 423.104(d)(5)(iii).