The Basics

This standard requires that your organization have a mechanism to handle both consumers' and prescribers' questions about how to obtain covered drugs when those drugs are not available within your PBM's network.

Now, it may be the case that your organization does not contract to provide this out-of-network service.  However, if you do handle this kind of service, your organization needs policies and procedures that describe how such a request should work.

The policies and procedures described in the standard must address both situations where a consumer cannot obtain covered drugs in a timely manner from participating pharmacy, or when the consumer is out of the service area and needs to obtain a covered medication.  It also might cover a situation in which the consumer order the medication through an in-network mail order pharmacy, but the prescription could not be filled in a timely manner.

Management Tips

The key here as you draft a policy and procedure for this is to anticipate the above possibilities and other situations in which the consumer cannot obtain covered medications in-network from any participating pharmacy.  In addition to a policy and procedure, however, you will need to think through how to properly implement such a policy and procedure, including training of customer service representatives on how to handle such inquiries.  Your pharmacy provider manual also probably should address this situation, as should any consumer facing materials for which such a process would be an appropriate disclosure.

URAC Accreditation Tips

This is a mandatory standard.

The desktop review will need documentation in the form of policies and procedures, provider manuals, and scripts for customer service resented his.

During the on-site review, and the focus will be on network management interviews, your complaint law, and any documentation you have of providing out-of-network services to your consumers.