Access to Care and Part D Drug Coverage
As a Medicare Advantage Organization (MAO), CDPHP is required by The Centers for Medicare & Medicaid Services (CMS) to have established processes to monitor the Federal Emergency Management Agency (FEMA) website at www.fema.gov in the event of a Presidential declaration of emergency or state of disaster and ensure that affected members receive open access to care without disruption.
The intent is to remove barriers to needed care and protect health care providers and pharmacies, including non-contracted providers, from incurring any financial penalty if conditions make it impossible or impractical to follow program requirements.
Access to Medical Care within the Provider Network
In the event of a Presidential declaration of emergency or state of disaster CDPHP must:
Allow medical care to be furnished by non-participating, non-contracted doctors, providers, and facilities.
Waive in full, or in part, any prior authorization and prior notification requirements without penalty to the provider or member.
Temporarily reduce plan approved out-of-network cost sharing amounts to an amount equal to the plan approved in-network cost sharing level.
Access to Pharmacy and Medications
In the event of a Presidential declaration of emergency or state of disaster, CDPHP must ensure that members have adequate access to covered Part D Drugs dispensed at any in or out-of-the network pharmacies and may:
Allow members to refill prescriptions at the point-of-sale prior to the established refill date.
Allow members to obtain the maximum extended day supply, if requested and available at the time of refill.
In addition to adhering to the CMS Federal Disaster Response requirements, CDPHP encourages doctors, providers, and facilities to contact CDPHP in the event of extenuating or unusual circumstances that may impede adherence to program requirements and/or affect access to care.