The URAC PBM Standards: Module 1: Definitions and Core

As I noted in the February 7 blog, the new URAC Pharmacy Benefit Management (“PBM”) accreditation standards are going through a beta process with a handful of brave applicants. Since that posting, however, we’ve got our hands on the official “Draft for Beta Testing” version. This version has a few significant changes from the “Draft for Public Comment” version released last year.
In this and the next few blogs, I’ll do a high-level analysis of the Beta Testing version, with brief commentary on changes from the Public Comment version.

Definitions

The PBM standards have a lot of concepts not included in the other accreditation standards. As a result, the “Definitions” section is substantially different than you’ll find in other Program Guides. Terms like “Automated review”, “Drug therapy management”, and “Generic substitution” are new. In addition, some terms that have appeared in other Program Guides take on new meanings in these standards, such as “Certification” and “Non-certification” have new, PBM-specific meanings. A close review of this section is, therefore, a must for anyone seeking to safely navigate these standards.

Module 1: Core

Naturally, as this is a clinical accreditation program, all applicants will be required to achieve a “passing score” on the Core module. Of course, as I’ve noted in a number of earlier blogs, this Core module (v.2.0) is changed from v. 1.0 and has some more rigorous standards than before (especially around patient safety).
Of particular interest to URAC during the beta testing period will be applicants’ compliance level with a couple of the Core standards:

• Core 3: The organization: (a) Maintains and complies with written policies and procedures that govern core business processes of its operations related to the scope of the accreditation; (b) Maintains a master list of all such policies and procedures; (c) Reviews clinical policies and procedures no less than annually and non-clinical at least once every three years, and revises as necessary; and (d) Includes the following on all policies and procedures: (i) Effective dates, review dates, including the date of the most recent revision; and (ii) Identification of approval authority.
• Core 10(c): “The organization designates at least one senior clinical staff person who has . . .Post-graduate experience in patient care.”