Specialty Pharmacy (4.0) 4.0

OPS 4-2: Verifying Eligibility

Submited by: Tom Goddard

The Basics

This standard requires that the pharmacy's policies promote medication management that is cost-effective. This includes processes such as substituting generic medications and reducing or avoiding polypharmacy if clinically indicated.

In addition, this standard requires that the pharmacy confirm that each patient is within the pharmacy's scope and has benefit coverage. 

Finally, the pharmacy must have processes to explore financial assistance when appropriate.

Management Tips

This standard likely will be addressed with two distinct policies, or in distinct sections of a larger program description. The first section should lay out the full array of cost-conscious strategies to be utilized by the pharmacy. Remember, URAC requires policies to assign accountability for processes, so identify which members of the staff will be in charge of the implementation of such strategies.

The second policy or program description section will need to describe who will be conducting verification of eligibility for services and assistance and the methods that person will use to conduct that verification. Be specific and detailed as you craft this language.

Accreditation Tips

Desktop Review

Submitting the policies described above will suffice at this phase of the review process.

Validation Review

The reviewer will discuss both categories of activities (cost-savings and verification) with the appropriate members of the staff.

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