The URAC PBM Standards: Module 3: Pharmacy Distribution Channel Standards

Resemblance to URAC's Plan and Network Standards

Not surprisingly, the 13 standards in this module look a lot like the Network Management (NM) standards from URAC’s Health Plan and Health Network accreditation programs. Indeed, there is an almost standard-to-standard relationship, e.g., PHARM-DC 1 with P-NM 1, PHARM-DC 2 with P-NM 2, and so on.
Thus, these standards cover what URAC has long thought to be the nuts-and-bolts of network management

• Defining the scope of services and provider selection criteria
• Working to achieve for access and availability
• Implementing policies for out-of-network services
• Provider relations program requirements
• Minimum components of provider agreements and subcontracts
• Provider dispute resolution

Of some interest to those of us who have closely followed the drama around URAC’s provider dispute resolution standards is that their correlates in the PBM standards avoid all the complications of their Plan and Network counterparts. Don’t look for much controversy here.

PBM-Specific Standards

The last two standards of this module, PHARM-DC 12 and 13, break from the Network Management pattern set by the first 11 standards. PHARM-DC 12 requires that the PBM’s claims processing comply with NCPDP transaction standards, while PHARM-DC 13 requires the PBM to disclose to consumers “the exceptions to refilling prescriptions (which would otherwise be limited by benefit design) in order to ensure access to the types of drug therapy needed.” This last standard doesn’t seem to fit in this module, and it wouldn’t surprise me in the least if PHARM-DC 13 were moved in the final draft to hang out with its closer cousins in consumer education in Module 2.