Selecting the right PBM partner to support and manage prescription drug benefits for your membership involves more than just looking at financial terms. PBM vendor selection also includes evaluating the quality and compliance of the services being delegated. However, comparing different PBMs based on qualitative measures can sometimes be a challenge, particularly if the PBM is not one you’ve worked within the past.

While there are several ways to apply qualitative measurement to any evaluation, a key component to selecting the right vendor is to understand the meaningfulness of PBM Certifications. In this blog, we will focus on two of the more dominant designations in the industry, NCQA and URAC accreditation.

What are NCQA and URAC?

NCQA (National Committee for Quality Assurance) – founded in 1990, this nonprofit organization works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation.

URAC (Utilization Review Accreditation Commission) – founded in 1990, this organization works to promote improvements in health care activities through collaboration and iteration.

What does it take an organization to become certified?

PBMs receive NCQA accreditation if claim processes, compliance standards, and policies and procedures meet strict guidelines across states and employers while protecting and improving member services. Specifically, NCQA evaluates these key areas:

  • Quality improvement
  • Disease Management
  • Wellness and Health Promotion
  • Population health management
  • Health Information Products
  • Case Management
  • Network management

For PBMs to receive URAC certification, organizations must demonstrate a commitment to quality care and improved patient outcomes through appropriate therapeutic outcomes, safe drug therapies, and ensuring up-to-date formularies. Specifically, URAC evaluates these key areas:

  • Customer service and communication benchmarks and safeguards
  • Financial disclosures mechanisms
  • Pharmacy distribution channels related to access, availability and quality, and safety across retail, mail order, and specialty pharmacy delivery systems
  • Drug use management standards in key areas, include coverage decisions, clinical review criteria, consumer safety process requirements, and the appeals process

PillarRx uses these industry designations when evaluating PBMs and client needs

A core service competency at PillarRx is leading all aspects of a PBM RFP. During the RFP process, PillarRx is asked to identify and provide accredited PBMs meeting local, state or federal mandates. NCQA and URAC accreditations/certifications are differentiators in the market for plans requiring these designations. Health Plans who carry one or both accreditations/certifications are particularly interested in partnering with PBMs who have these designations, as it can provide congruent compliance support to the plan in key areas delegated to PBM partners.

PillarRx clients, especially health plans and those looking to expand into government-sponsored program offerings, want a PBM that’s NCQA and/or URAC accredited/certified. PBMs holding these credentials allows health plans to attract new member groups. Plans looking to offer additional lines of business such as Medicare, Medicaid, ACA Exchange desire accreditations/certifications, knowing the level of standard accountability and quality these PBMs provide for members across government programs.

If you are looking for a new PBM partner and want to know if they are currently NCQA and/or URAC accredited/certified, or would like a better understanding of these designations, contact PillarRx at [email protected]

It’s important to note that PillarRx works across PBMs that are NCQA and/or URAC accredited/certified and also with PBM partners that don’t have either accreditation/certification.