Pharmacy Benefit Management

On June 7, 2006 URAC announced the formation of a Pharmacy Benefit Management Standards Committee to advise the organization on the creation of requirements for the first-ever accreditation programs addressing pharmacy benefits management in the Medicare, commercial insurance and health plan arenas.

Recognizing that one of every five health care dollars is spent on prescription drugs, and knowing that currently there is no independent accreditation program to ensure quality in pharmacy benefit management, URAC has identified this move as an opportunity to enhance patient safety, assure timely access to prescription medications and to improve medication therapy management.

Currently, pharmacy benefit management companies (PBMs) contract with 95 percent of retail pharmacies nationwide[1]. With the introduction of the Medicare Part D prescription drug benefit this year, the number of Americans enrolled in PBM programs is expected to grow dramatically. Currently more than 38 million Medicare beneficiaries are enrolled in a prescription drug program.[2] Medicare prescription drug spending alone over the next 10 years is projected to reach between $500 billion and $1.2 trillion.[3] Prior to implementation of the Medicare Part D program, only 70 percent of adults with chronic conditions received recommended medications.[4]

The goal of the program is to create a pharmacy benefit management accreditation program for the commercial and Medicare markets that promotes industry best practices; encourages quality improvement; and protects and empowers consumers.

Accreditation sets industry-wide clinical and operational standards and brings a recognizable seal of quality to accredited organizations. It is URAC's goal to develop accreditation standards and provide the assurance that, notwithstanding different business models, the content of what is provided to clients and their members meets acceptable standards.

The initial set of standards is designed for the commercially insured population. The standards are being developed by URAC’s Pharmacy Benefit Management Advisory Committee, which includes a wide range of stakeholders: employers, consumers, pharmacy consultants, health plans, independent retail pharmacy, pharmacy benefit management organizations, pharmacy professional organizations, labor, and large public purchasing groups.

  1. Congressional testimony of Mark Merritt, May 23, 2006.
  2. CMS, May 16, 2006
  3. “Medicare Drug Benefit May Cost $1.2 Trillion,” Washington Post, Feb, 9, 2005.
  4. The Quality of Health Care Delivered to Adults in the United States, McGlynn E. A., Asch S. M., Adams J., Keesey J., Hicks J., DeCristofaro A., Kerr E. A., N Engl J Med 2003; 348:2635-2645, Jun 26, 2003.

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