The Basics

This standard requires that the organization implement policies and procedures to describe how it will handle the situation where a drug is excluded.  It relates to a client-specific request by the consumer, prescriber, or pharmacist to request the addition of an excluded drug to the defined-benefit formulary.  As was the case for exceptions, the policy and procedure may simply note that this will be handled by the benefit administrator.  However, should there be any instances in which the PBM handles a request for inclusion of an excluded drug in formulary, the policy and procedure should describe in some detail how the PBM will handle that request.

Management Tips

It is important to make sure that the policy and procedure is sufficiently explicit about how your organization will handle a request for inclusion of an excluded drug.  If there are no circumstances under which the PBM handles this, make that clear in the policy and procedure.

URAC Accreditation Tips

This standard has a weight of 2.

The only documentation necessary at the desktop review level will be the policy and procedure that applies to exclusions.

For the on-site review, make sure that the staff is trained on the organization's policy and procedure for exclusions.  In addition, the reviewer may examine committee meeting minutes, a client contract for exclusion mechanisms, and the consumer complaint log for evidence of compliance with the standard.