Pharmacy benefit management organizations (PBMs) now can seek URAC’s quality seal of approval with the introduction of the first-ever voluntary accreditation standards for the industry. 

For employers and employees, this approach represents another step in providing guidance on choosing a plan that can be effective for specific organizations.

URAC is an independent, nonprofit organization that promotes health care quality through its accreditation and certification programs.

Pharmacy benefit management is a rapidly growing health care sector. Pharmacy related expenses in the United States were expected to reach $250 billion in 2006, representing an 11.5 percent increase over 2005. The sector saw rapid expansion with the introduction of Medicare Part D prescription drug coverage in 2006, with more than 39 million Medicare beneficiaries (90 percent) now enrolled in that program.

Currently, about 70 percent of Americans receive their prescription medications through pharmacy benefit management companies, but until now there was no comprehensive assurance for consumers and purchasers that quality standards were met for consumer protection and empowerment, appropriate access to drugs and pharmacies, patient safety, and disclosure of pricing and contracting terms. 

URAC created the program to promote industry best practices, encourage quality improvement, and protect and empower consumers.  The Pharmacy Benefit Management Accreditation program, for health plans and stand alone PBM organizations in the commercial market, is the culmination of more than a year of standards development and testing, engaging all major stakeholder groups and a field team of expert reviewers in the standards development and standards review process.

Initial standards underwent a public review and comment period, then field testing by a dozen pharmacy benefit management organizations, including United HealthCare’s Prescription Solutions, Inc.; Express Scripts, Inc.; PerformRx; MedImpact HealthCare Systems; Prime Therapeutics LLC; Catalyst Rx; Envision Pharmaceutical Services; AETNA, Inc.; and Navitus Health Solutions, LLC. The group together represents 52 percent of the current lives covered under pharmacy benefit management programs across the nation.

"URAC Pharmacy Benefit Management Accreditation will provide consumers with greater confidence that the companies which are behind the scenes managing their pharmacy benefits are dedicated to quality improvement, and that they have made the necessary investments into the clinical expertise and oversight that is necessary to manage an effective program in today’s environment," said Alan P. Spielman, URAC’s president and chief executive officer. "For purchasers, accredited companies can demonstrate that they clearly disclose their pricing methodologies and offer the services and protections consumers need as they deal with the complex world of pharmacy benefits management."

"The standards address key areas for any pharmacy benefit organization, but allow for innovation," said John Jones, RPh, JD, chairman of URAC’s PBM Standards Committee and vice president of professional practice and pharmacy policy at Prescription Solutions. "Clinical rigor, such as the qualifications of staff who make decisions about drugs included in a formulary and how those decisions are made, is one notable area. The standards also seek a very sound operational base and address regulatory compliance issues, such as oversight of information disclosure to consumers, providers and pharmacists.

"The accreditation program is really focused on making sure organizations do what is right by the consumer, including standards for appeals procedures and making sure they have access to the drugs they need," Jones added. "I know that regulatory bodies, such as state departments of insurance or state boards of pharmacy, are looking at ways they can consider this accreditation as a proxy for their development of laws and regulations. The states don’t want to be experts in PBM accreditation. They’ve got other work to do."

To read more about the URAC Pharmacy Benefit Management Accreditation program go to www.urac.org