The Basics

This standard addresses a situation where a consumer needs a drug that would otherwise be excluded by his or her benefit plan, but still should get the medication.  It addresses situations like natural disaster, lost supplies, prescriptions needed before a long journey, or damaged medications.  The standard requires that your organization have a clear policy and procedure that allows for such exceptions and describes precisely how they are to be handled so that the consumer is not without needed medication.

Management Tips

Writing a policy and procedure to cover this requirement is the easy part.  The more challenging part is to make sure that the appropriate customer service and other staff members are adequately trained on how to handle these unusual circumstances.  Therefore, work closely with your training department to make sure that your policies and procedures are fully implemented.  It is also important to remember that while most of the situations that arise under this standard will be on a case-by-case basis, in some instances, notably natural disaster, you may be dealing with many affected consumers at one time.  Make sure your policies and procedures are sufficiently robust to address such a situation.

URAC Accreditation Tips

This is a mandatory standard.

The initial documentary submissions should include your policies and procedures for refills, as well as any script that you have developed for customer service Representatives to implement those policies.  In addition, if you have regulations at the federal or state level that address these issues, be sure to include them in your submission.

The reviewer will interview of customer service staff and the compliance officer to assess understanding of how your organization complies with the standard.  In addition, the reviewer's examination of your complaint log may also lead to an inquiry about the implementation of the standard in the event that complaints reveal that you have not fully implemented your policies and procedures.