Rural Access Compliance Rules Proposal by Glenn Disher - PBM Investigator

 
GEO ACCESS RURAL RULES
PROPOSAL
 
Glenn Disher
PBM Compliance Investigator
 
10/21/2021
 
Goal
 
To consider local conditions and focus enforcement
for maximum impact
 
 
Rural Zip Code Rule
Recommendations
 
10 Live/Member Rule
Under 10 Lives per Zip Code – Waive compliance standards
10 Lives plus per Zip Code – Compliance standards Apply
No Pharmacy within access mileage standard – PBM is considered
compliant
Pharmacy within access mileage standard
Letter sent requesting additional information of qualifying
offer
»
PBM offered qualifying contract – PBM is considered
compliant
»
No qualifying contract offered – PBM is not compliant
Refer to OID Legal for enforcement
 
 
Statuary Compliant Mileage Rule
Rural Area Zip with greater than 50% Members with access &
compliant average mileage – PBM is considered compliant
Rural Area Zip with less than 50% Members with access & non-
compliant mileage – PBM is considered non-compliant
Letter sent requesting additional information
Qualifying contract offer – PBM is compliant
No qualifying contract offered – PBM is not compliant
Refer to OID Legal for enforcement
Coffeyville Rule
Contracted Pharmacy outside of jurisdiction, State of Oklahoma,
but within mileage standard – PBM is compliant
 
 
 
PBM Non-Compliant Rural Zip
Examples
 
Small PBM
Total Non-Compliant Rural Zip Codes – 47
Non-Compliant Zip Codes with 10+ Members – 4
Avg membership for less then 10 Member Zip – 3.7
Avg Distance of Non-Compliant Zip to nearest Rx – 20.4mi
Total Members without access – 162 or 2.3% of Total Rural Members
 
Medium PBM
Total Non-Compliant Rural Zip Codes – 30
Non-Compliant Zip Codes with 10+ Members – 5
Avg membership for less then 10 Member Zip – 2
Avg Distance of Non-Compliant Zip to nearest Rx – 16.9mi
Total Members without access – 155 or 2.3% of Total Rural Members
 
Large PBM – One network
Total Non-Compliant Rural Zip Codes – 126
Non-Complaint Zip Codes with 10+ Members – 34
Avg membership for less then 10 Member Zip – 7.9
Avg Distance of Non-Compliant Zip to nearest Rx – 20.9mi
Total Members without access – 1,634 or 2.9% Total Rural Members
 
All PBM potential Geo Access
Violations
 
Total Number of potential violations before the 10
Member Rule
1,118
After application of the 10 Member Rule
 
474 or 44% of the total number of violations
 
Slide Note
Embed
Share

Proposal by Glenn Disher, a PBM Compliance Investigator, outlines rules for rural access compliance. The proposal focuses on considering local conditions and enforcing rules for maximum impact. It includes recommendations for zip code rules, compliance mileage rules, and examples of non-compliant rural zip codes. The proposal also addresses potential violations before and after the implementation of specific membership rules.


Uploaded on Sep 06, 2024 | 0 Views


Download Presentation

Please find below an Image/Link to download the presentation.

The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.

E N D

Presentation Transcript


  1. GEO ACCESS RURAL RULES PROPOSAL Glenn Disher PBM Compliance Investigator 10/21/2021

  2. Goal To consider local conditions and focus enforcement for maximum impact

  3. Rural Zip Code Rule Recommendations 10 Live/Member Rule Under 10 Lives per Zip Code Waive compliance standards 10 Lives plus per Zip Code Compliance standards Apply No Pharmacy within access mileage standard PBM is considered compliant Pharmacy within access mileage standard Letter sent requesting additional information of qualifying offer PBM offered qualifying contract PBM is considered compliant No qualifying contract offered PBM is not compliant Refer to OID Legal for enforcement

  4. Statuary Compliant Mileage Rule Rural Area Zip with greater than 50% Members with access & compliant average mileage PBM is considered compliant Rural Area Zip with less than 50% Members with access & non- compliant mileage PBM is considered non-compliant Letter sent requesting additional information Qualifying contract offer PBM is compliant No qualifying contract offered PBM is not compliant Refer to OID Legal for enforcement Coffeyville Rule Contracted Pharmacy outside of jurisdiction, State of Oklahoma, but within mileage standard PBM is compliant

  5. PBM Non-Compliant Rural Zip Examples Small PBM Total Non-Compliant Rural Zip Codes 47 Non-Compliant Zip Codes with 10+ Members 4 Avg membership for less then 10 Member Zip 3.7 Avg Distance of Non-Compliant Zip to nearest Rx 20.4mi Total Members without access 162 or 2.3% of Total Rural Members Medium PBM Total Non-Compliant Rural Zip Codes 30 Non-Compliant Zip Codes with 10+ Members 5 Avg membership for less then 10 Member Zip 2 Avg Distance of Non-Compliant Zip to nearest Rx 16.9mi Total Members without access 155 or 2.3% of Total Rural Members Large PBM One network Total Non-Compliant Rural Zip Codes 126 Non-Complaint Zip Codes with 10+ Members 34 Avg membership for less then 10 Member Zip 7.9 Avg Distance of Non-Compliant Zip to nearest Rx 20.9mi Total Members without access 1,634 or 2.9% Total Rural Members

  6. All PBM potential Geo Access Violations Total Number of potential violations before the 10 Member Rule 1,118 After application of the 10 Member Rule 474 or 44% of the total number of violations

  7. Oklahoma Insurance Department | Insurance Commissioner Glen Mulready | 800.522.0071

Related


More Related Content

giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#