URAC PBM Accreditation Consulting
Last updated: October 2026
URAC PBM Accreditation consulting helps a pharmacy benefit manager (PBM) prepare for URAC Pharmacy Benefit Management Accreditation, from a Standard-by-Standard Review through the validation review. URAC accredits pharmacy benefit managers (URAC PBM Accreditation).
Integral Healthcare Solutions (IHS), founded in 2002 by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC, is a specialized healthcare accreditation consulting firm. IHS has served as lead consultant for URAC Pharmacy Benefit Management Accreditation since the original beta applications in 2007, covering every version from v1.0 through the current v4.0 standards. IHS drafts the policies and evidence for your clinical and legal leaders to review and approve, and your organization's named contact makes the submission to URAC.
What is URAC Pharmacy Benefit Management Accreditation?
URAC Pharmacy Benefit Management Accreditation is a quality credential for PBMs. It covers pharmacy operations, drug utilization management, formulary governance, customer service and performance measurement. The current standard is PBM Accreditation v4.0. Accreditation lasts three years and involves five formal phases: application submission, desktop review, validation review, committee review and ongoing monitoring.
The FTC's interim staff report on PBMs, released July 9, 2024, states that the top three PBMs processed nearly 80 percent of the roughly 6.6 billion prescriptions dispensed by U.S. pharmacies in 2023, and the top six more than 90 percent. The report also says vertically integrated PBMs appear to have the ability and incentive to prefer their own affiliated businesses, creating conflicts of interest (FTC press release, page opened October 4, 2026).
URAC accreditation serves as external validation that your organization operates transparently, ethically and to measurable quality standards.
Which URAC PBM quality modules does the standard cover?
URAC PBM Accreditation v4.0 evaluates organizations across 10 quality modules. These are six of them.
- PHARM Core (Pharmacy Core Operations): regulatory compliance policies, inter-departmental coordination procedures, delegation oversight contracts, IT security logs, business continuity plans and HR competency assessments. This module touches every operational area.
- CSCD (Customer Service, Communications, Disclosure): welcome packet distribution logs, call center performance metrics, complaint and grievance process documentation and out-of-pocket cost disclosures.
- PHARM-DC (Pharmacy Distribution Channel): network pharmacy credentialing protocols, geographic access analyses, participating pharmacy dispute resolution workflows and temperature management logs for mail-order and specialty drug distribution.
- DrUM (Drug Utilization Management): coverage decision algorithms based on clinical information, prior authorization rationales, step-therapy protocols and standard and expedited appeals timeline policies.
- PTFD (P&T Standards / Formulary Development): Pharmacy and Therapeutics committee meeting minutes, clinical versus economic consideration methodologies, conflict of interest policies and new molecular entity evaluation workflows.
- RPT (Performance Measurement Reporting): data systems that track and submit annual performance metrics, including generic dispensing rates, call abandonment rates and dispensing accuracy. URAC-accredited PBMs report these metrics annually throughout the three-year cycle.
The remaining four modules cover quality management oversight, organizational compliance infrastructure, clinical program governance and continuous improvement requirements. Each module requires specific documentation, measurable outcomes and audit-ready evidence.
What is the URAC PBM accreditation process, and how long does it take?
IHS plans for 9 to 12 months from consulting engagement kickoff to the final accreditation committee decision, an IHS planning range that includes three to six months of preparation before document submission.
Phase 1: Standard-by-Standard Review (month 1)
IHS meets with your internal teams and walks through every applicable URAC standard. The output is a deficiency report that becomes your project roadmap. IHS reviews actual policies, procedures, workflows and documentation against each of the 10 quality modules and identifies the gaps to close before submission.
Phase 2: Policy development and remediation (months 2-4)
This is the heaviest lift of the engagement. IHS supplies policy templates aligned with v4.0 requirements and works alongside your internal legal and clinical teams to draft missing workflows. Every policy must align with both URAC requirements and applicable state laws, which vary by state. For organizations that bid on state government contracts, IHS reads each RFP's accreditation requirement at the same time.
Phase 3: Mock Desktop Review (month 5)
IHS simulates URAC's desktop review against your drafted documentation and assesses whether your policies comply with surveyor expectations as well as the written standards. You receive feedback on every deficiency found.
Phase 4: Document submission (month 6)
Your organization submits its documents by the deadline URAC sets, and the desktop review begins. Contextual information, workflows and sample reports are uploaded into AccreditNet, URAC's web-based platform. IHS organizes and formats the documentation for your organization's upload so it is complete and efficient for reviewers to use.
Phase 5: Desktop review and RFI response (months 7-8)
URAC clinical reviewers score your uploaded policies over a 30 to 45-day window. When reviewers issue Requests for Information (RFIs) on standards scored as "Not Met," IHS drafts revisions for your team. IHS drafts RFI responses on the PBM standards and translates reviewer feedback into compliant documentation.
Phase 6: Mock Validation Review (month 9)
IHS conducts a Mock Validation Review, either virtually or on-site, questioning your staff and leadership to confirm they can explain policies in practice. The validation review is not a documentation exercise. It tests whether your team understands and can defend the policies under direct surveyor questioning.
Phase 7: Official validation survey and committee review (months 10-11)
The formal URAC audit spans 1 to 3 days and may be conducted virtually, on-site or as a hybrid. An anonymous redacted report is then submitted to the URAC Accreditation Committee for final determination. The committee then issues its decision. Provisional Accreditation comes earlier, when the Accreditation Committee grants it after the desktop review and the Request for Information, and it lasts 18 months.
Why is PBM accreditation a current priority?
Federal and state rules bear on PBM accreditation decisions, and these are the main ones.
State procurement requirements
South Carolina's State Health Plan pharmacy benefits management solicitation (PEBA0442024, issued December 17, 2024) lists current URAC accreditation in pharmacy benefits management as a mandatory minimum qualification for an offeror, with offers due February 20, 2025 (South Carolina Public Employee Benefit Authority, RFP PEBA0442024, section 4.2, page opened October 6, 2026). If your PBM bids on a state government contract, read the accreditation requirement in each RFP closely.
CAA 2026 federal transparency requirements
The Consolidated Appropriations Act, 2026 (Public Law 119-75, enacted February 3, 2026) adds PBM requirements for group health plans in section 6701, including drug-level data reporting to the plan, for plan years beginning on or after the date 30 months after enactment. For Medicare Part D, section 6224 requires, for plan years beginning on or after January 1, 2028, that a PBM acting for a plan sponsor and its affiliates derive no remuneration in connection with the utilization of covered Part D drugs other than bona fide service fees, subject to the exceptions the section lists (Public Law 119-75, page opened October 4, 2026). The Department of Labor proposed a rule under ERISA section 408(b)(2) that would require PBMs to disclose their compensation to fiduciaries of self-insured group health plans. It was published in the Federal Register on January 30, 2026, and its comment period closed April 15, 2026 (91 FR 4348, 91 FR 10033 and the EBSA fact sheet, pages opened October 6, 2026).
FTC scrutiny
The FTC's 2024 interim staff report described how vertically integrated PBMs can create conflicts of interest that disadvantage unaffiliated pharmacies, as summarized above (FTC press release, page opened October 4, 2026). URAC accreditation serves as external validation that your organization's utilization management practices, pricing transparency and clinical governance meet independent quality standards.
State-level PBM reform
Several states have enacted PBM laws that change how PBMs are paid and what they report. Colorado's House Bill 25-1094 (C.R.S. 10-16-122.8) bars a pharmacy benefit manager from earning income based on the price or cost of a prescription drug and takes effect January 1, 2027. California's SB 41 (Chapter 605, Statutes of 2025) limits a pharmacy benefit manager's income to a stated management fee, requires pass-through pricing, and sets Department of Managed Health Care licensure from January 1, 2027 or when the department's process exists, whichever is later. Utah's H.B. 257 (2025) requires health benefit plans renewed or entered into on or after July 1, 2026 to use manufacturer rebates for enrollees, through point-of-sale reductions, lower premiums or richer benefits. Iowa's Senate File 383 (2025) requires pharmacy benefits managers to file a quarterly report with the commissioner on drugs reimbursed 10 percent or more below or above the national average drug acquisition cost, and to publish a copy. Louisiana's Act 474 (House Bill 264, 2025) bars rebate retention, requires PBM fees to be disclosed in writing in the contract and sets an annual March 1 transparency report, with enforcement of the rebate-retention and spread-pricing provisions beginning January 1, 2027. Massachusetts Chapter 342 of the Acts of 2024 (Senate Bill 3012) requires pharmacy benefit managers to be licensed by the Division of Insurance by January 1, 2026. Each act was opened at the legislature's site linked on October 6, 2026.
Which areas does IHS review closely before a URAC PBM survey?
A gap in any of these areas can lead to an RFI in a URAC PBM survey. For each one, IHS builds the schedules, templates, trackers or review triggers that produce audit-ready evidence.
- Primary source verification (PHARM Core): clinical staff credentials not verified directly from primary sources, or not verified at the frequency internal policy sets.
- Clinical assessment documentation (DrUM): missing or incomplete documentation of patient management and clinical rationales for drug utilization review decisions.
- Temperature management and distribution (PHARM-DC): inadequate qualification testing, auditing and logging of temperature controls for mail-order or specialty drug distribution.
- HR competency assessments (PHARM Core): incomplete documentation that staff hold the competencies and training their roles require.
- Welcome packet documentation (CSCD): no auditable trail that newly enrolled members received required welcome materials and benefit disclosures.
- State regulatory agency information (CSCD): member grievance and complaint packets that omit state regulatory agency contact information.
- Procedure manual version control (PHARM Core): printed procedures that do not match electronic documents, or superseded policies that are not archived.
- Acceptance criteria (PHARM Core Quality): mandatory quality improvement projects without defined, measurable acceptance criteria.
- Leadership oversight (PHARM Core): no evidence that senior clinical staff actively manage proficiency testing and QA, such as missing signed minutes or participation logs.
- Activity menus (PHARM Core): scopes of service that stay static after technology, clinical or process changes.
How does IHS help with URAC PBM accreditation?
The IHS process covers Standard-by-Standard Review, document and evidence mapping, policy drafting for your leaders to approve, a Mock Desktop Review and a Mock Validation Review, and readiness support through RFIs. IHS uses Starfinch, its own tool, to track the work.
- PBM record since 2007: IHS has served as lead consultant for URAC PBM accreditation since the original beta applications in 2007. IHS has guided organizations through every standards version from v1.0 through the current v4.0.
- Modular services: not every PBM needs full-cycle consulting. IHS offers a standalone Standard-by-Standard Review, Mock Desktop Review, Mock Validation Review, RFI response support and ongoing compliance retainers, so you engage for what you need.
What internal staff does a PBM need?
URAC PBM accreditation needs dedicated internal resources working beside IHS, and these are the roles to plan for.
- Internal accreditation coordinator (1.0 FTE): the primary liaison between IHS and your operational teams across the 9 to 12-month lifecycle. Without one, documentation gaps can accumulate and timelines can slip.
- Senior clinical leadership (fractional FTE): your Chief Medical Officer or senior PharmD serves as P&T committee chair and defends drug utilization management algorithms during the validation review.
- Information security and IT leaders (fractional FTE): HIPAA compliance documentation and annual performance reporting need IT leadership at key milestones.
- Quality management director (fractional FTE): your Quality Management Committee and improvement projects need a quality leader who can show measurable outcomes and continuous improvement.
What does URAC PBM accreditation cost?
The cost has three parts: URAC's own fees, IHS's consulting fee and your internal staff time. URAC sets its own fees, and this page gives no URAC fee figure, so your organization's named contact obtains current fee information from URAC when you budget. Your internal time is driven by the staffing roles above and the 9 to 12-month plan.
IHS sets a fixed fee for each engagement after a free discovery session, because scope, number of sites and gap severity change the work. The PBM Accreditation Cost Guide breaks the parts down further.
What this is not
- IHS is not URAC and is not an accrediting body. IHS does not grant or influence an accreditation decision.
- IHS drafts the application text, and your organization's named contact files it and answers URAC. IHS does not communicate with URAC for you.
- This page is not legal advice, and no consulting engagement guarantees an accreditation outcome.
From Tom's experience
On a call reviewing mock validation review findings, Tom said: “I have never done a mock validation review, even with clients that I've worked with for fifteen, twenty years, in which I didn't find something.”
On a client call after a mock validation review, Tom said: “… the best preparation for your staff. For the validation review is to know exactly what they should be doing and be able to document that they are doing what your policies say they should be doing.”
Thomas G. Goddard, JD, PhD
Frequently asked questions
Who needs URAC PBM accreditation?
PBMs that bid on state government contracts whose RFPs set URAC PBM accreditation as a requirement. South Carolina's State Health Plan pharmacy benefits management RFP (PEBA0442024) lists current URAC accreditation as a mandatory minimum qualification. Read the accreditation requirement in each RFP you bid on.
How long does URAC PBM accreditation take?
IHS plans 9 to 12 months from consulting kickoff to the committee decision, including three to six months of preparation before document submission.
How much does URAC PBM accreditation cost?
The cost is URAC's fees, IHS's consulting fee and your internal time. This page gives no URAC fee figure, and your organization's named contact obtains current fee information from URAC. IHS sets a fixed fee for each engagement after a free discovery session.
What does a URAC PBM accreditation consultant do?
IHS runs a Standard-by-Standard Review, drafts policies for your leaders to approve, conducts a Mock Desktop Review and a Mock Validation Review and drafts RFI responses. IHS organizes and formats the documentation for your organization's AccreditNet upload, and your named contact submits.
How does URAC PBM accreditation relate to CAA 2026?
The Consolidated Appropriations Act of 2026 sets federal PBM transparency requirements, and URAC PBM accreditation is a separate quality credential. IHS connects the two so that one compliance infrastructure serves both.
Who is this not for?
A PBM that needs legal advice on PBM law, or one that wants IHS to deal with URAC directly, is not a fit. IHS drafts for your named contact, who files, and IHS is not a law firm.
Related services
PBMs pursuing URAC accreditation may also need support in adjacent areas. IHS consults on URAC and NCQA programs under its Accreditation Consulting practice line. Maureen Plumstead leads IHS's NCQA accreditation and recognition work.
- If your PBM is part of a vertically integrated health plan, see our URAC Health Plan Accreditation consulting.
- If you need credentialing program design for your pharmacy network, see our Credentialing Program Design and Credentialing Certification consulting.
- For a detailed cost breakdown, see our PBM Accreditation Cost Guide.
- For answers to specific questions, see our PBM Accreditation FAQ.
- To understand how PBM accreditation compares to health plan accreditation, see our PBM vs Health Plan Accreditation Comparison.
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