Rural Access Compliance Rules Proposal by Glenn Disher - PBM Investigator
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.
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Presentation Transcript
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
Oklahoma Insurance Department | Insurance Commissioner Glen Mulready | 800.522.0071
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