Drug interaction review methods and systems

• US 10,366,462 B1
• Filed: 03/26/2013
• Issued: 07/30/2019
• Est. Priority Date: 03/26/2012
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Inventors: Miller, Steven B.
• Primary Examiner(s): Cobanoglu, Dilek B
• Application Number:
  US13/850,476
• Time in Patent Office: 2,317 Days
• Field of Search: 705 2, 705 3, 221 2
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 50/22 Social work or social welfare, e.g. community support activities or counselling services
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

Methods and systems for drug interaction review are described. In an example embodiment, a prescription request is received for a prescription drug. The prescription drug is associated with a prescription. A determination that the prescription drug is a controlled substance is made. Pharmacy claims data is analyzed to determine whether past claims adjudication data is associated with a patient controlled substance identifier. The patient controlled substance identifier is associated with a patient that has been prescribed the prescription drug through the prescription without identifying the patient as being a member of a benefit manager. The prescription request is evaluated based on a determination that the past claims adjudication data is associated with the patient controlled substance identifier. A notification is generated based on evaluation of the prescription request. Additional methods and systems are disclosed.

Claims

1. A method comprising:

receiving over a network, on a benefit manager device, a prescription request for a prescription drug from at least one of a prescriber device and a pharmacy device, the prescription drug being associated with a prescription;

determining, on the benefit manager device, that the prescription drug is a controlled substance;

determining, on the benefit manager device, that a patient for whom the prescription drug was prescribed has not provided a member identifier of a drug benefit plan;

associating, on the benefit manager device, the prescription request with a controlled substance identifier, wherein the controlled substance identifier is also associated with the prescription drug, wherein the controlled substance identifier is generated based on a prescriber associated with the prescription, a pharmacist associated with the prescription, a pharmacy associated with the prescription, a cash identifier associated with the prescription, a timing associated with the prescription, or combinations thereof, and wherein the controlled substance identifier is not generated based on patient identification information;

analyzing, on the benefit manager device, pharmacy claims data to determine whether past claims adjudication data is associated with the controlled substance identifier, the past claims adjudication data associated with the controlled substance identifier also does not include the patient identification information;

evaluating, on the benefit manager device, the prescription request to determine whether the past claims adjudication data associated with the controlled substance identifier indicates that the prescription drug has been dispensed in a claim associated with the controlled substance identifier within a predetermined time of the prescription request;

generating, on the benefit manager device, a notification based on evaluation of the prescription request;

transmitting the notification from the benefit manager device via the network to at least one of the pharmacy device and the prescriber device, the notification indicating whether to dispense or not dispense the prescription drug; and

dispensing the prescription drug when the notification indicates to dispense the prescription drug.

2. The method of claim 1, further comprising:

generating the controlled substance identifier,

wherein analysis of the pharmacy claims data is performed based on generation of the controlled substance identifier and receipt of the prescription request.

3. The method of claim 1, further comprising:

determining that the prescription request is associated with a cash purchase of the prescription drug,

wherein analysis of the pharmacy claims data is in response to a determination that the prescription request is associated with the cash purchase.

4. The method of claim 3, further comprising:

selecting cash purchase pharmacy claims data among the pharmacy claims data based on a determination that the prescription request is associated with the cash purchase,

wherein analysis of the pharmacy claims data is performed on the cash purchase pharmacy claims data to determine whether the past claims adjudication data is associated with the controlled substance identifier.

5. The method of claim 1, wherein analyzing the pharmacy claims data comprises:

selecting the past claims adjudication data from the pharmacy claims data based on a time criterion; and

determining whether the past claims adjudication data is associated with the controlled substance identifier.

6. The method of claim 1, further comprising:

transmitting a response based on the notification.

7. The method of claim 1, wherein the prescription request is an adjudication request to adjudicate the prescription for the patient, and wherein evaluating the prescription request includes performing a drug interaction review on the prescription drug based on the past claims adjudication data.

8. The method of claim 7, further comprising:

identifying a past prescription associated with the past claims adjudication data,

wherein performance of the drug interaction review for the prescription drug is based on the past prescription.

9. The method of claim 7, wherein performance of the drug interaction review is performed as part of performing a drug utilization review (DUR) for the prescription drug based on the past claims adjudication data.

10. The method of claim 7, further comprising:

recording payment to a pharmacy based on receipt of the adjudication request.

11. The method of claim 1, wherein the prescription includes the controlled substance identifier.

12. The method of claim 1, wherein the past claims adjudication data does not include indicium that directly identifies the patient.

13. The method of claim 1, wherein the notification includes an amount to be paid to a pharmacy based on dispensing of the prescription drug.

14. A method comprising:

receiving, over a network, on a benefit manager device, a prescription request for a prescription drug from at least one of a prescriber device and a pharmacy device, the prescription drug being associated with a prescription;

determining, on the benefit manager device, whether the prescription meets controlled substance criteria, the controlled substance criteria including that the prescription drug is a controlled substance and a patient has not provided a member identifier that identifies a member of a benefit manager;

associating, on the benefit manager device, the prescription request with a controlled substance identifier, wherein the controlled substance identifier is also associated with the prescription drug, and wherein the controlled substance identifier is based on a prescriber associated with the prescription, a pharmacist associated with the prescription, a pharmacy associated with the prescription, a cash identifier associated with the prescription, a timing associated with the prescription, or combinations thereof, and wherein the controlled substance identifier is not based on patient identification information;

analyzing, on the benefit manager device, pharmacy claims data to determine whether past claims adjudication data is associated with the controlled substance identifier, the past claims adjudication data associated with the controlled substance identifier also does not include the patient identification information;

evaluating, on the benefit manager device, the prescription request to determine whether the past claims adjudication data associated with the controlled substance identifier indicates that the prescription drug has been dispensed in a claim associated with the controlled substance identifier within a predetermined time of the prescription request;

generating, on the benefit manager device, a notification based on evaluation of the prescription request;

transmitting the notification from the benefit manager device via the network to at least one of the pharmacy device and the prescriber device, the notification indicating whether to dispense or not dispense the prescription drug; and

dispensing the prescription drug when the notification indicates to dispense the prescription drug.

15. The method of claim 14, wherein the prescription request is an adjudication request to adjudicate the prescription for the patient, and wherein evaluating the prescription request includes performing a drug interaction review on the prescription drug based on the determination that the prescription meets the controlled substance criteria.

16. A non-transitory machine-readable medium comprising instructions, which, when executed by one or more processors, cause the one or more processors to perform the following operations:

receive, over a network on a benefit manager device, a prescription request for a prescription drug from at least one of a prescriber device and a pharmacy device, the prescription drug being associated with a prescription;

determine, on the benefit manager device, that the prescription drug is a controlled substance;

determine, on the benefit manager device, that a patient for whom the prescription drug was prescribed has not provided a member identifier of a drug benefit plan;

associate, on the benefit manager device, the prescription request with a controlled substance identifier, wherein the controlled substance identifier is also associated with the prescription drug, and wherein the controlled substance identifier is generated based on a prescriber associated with the prescription, a pharmacist associated with the prescription, a pharmacy associated with the prescription, a cash identifier associated with the prescription, a timing associated with the prescription, or combinations thereof, and wherein the controlled substance identifier is not generated based on patient identification information;

analyze, on the benefit manager device, pharmacy claims data to determine whether past claims adjudication data is associated with the controlled substance identifier, the past claims adjudication data associated with the controlled substance identifier also does not include the patient identification information;

evaluate, on the benefit manager device the prescription request to determine whether the past claims adjudication data associated with the controlled substance identifier indicates that the prescription drug has been dispensed in a claim associated with the controlled substance identifier within a predetermined time of the prescription request;

generate, on the benefit manager device a notification based on evaluation of the prescription request;

transmit the notification from the benefit manager device via the network to at least one of the pharmacy device and the prescriber device, the notification indicating whether to dispense or not dispense the prescription drug; and

cause a pharmacy to dispense the prescription drug when the notification indicates to dispense the prescription drug.

17. A non-transitory machine-readable medium comprising instructions, which, when executed by one or more processors, cause the one or more processors to perform the following operations:

receive, over a network on a benefit manager device, a prescription request for a prescription drug from at least one of a prescriber device and a pharmacy device, the prescription drug being associated with a prescription;

determine, on the benefit manager device, whether the prescription meets a controlled substance criteria, the controlled substance criteria including that the prescription drug is a controlled substance and a patient has not provided a member identifier that identifies a member of a benefit manager;

associate, on the benefit manager device, the prescription request with a controlled substance identifier, wherein the controlled substance identifier is also associated with the prescription drug, and wherein the controlled substance identifier is generated based on a prescriber associated with the prescription, a pharmacist associated with the prescription, a pharmacy associated with the prescription, a cash identifier associated with the prescription, a timing associated with the prescription, or combinations thereof, and wherein the controlled substance identifier is not generated based on patient identification information;

analyze, on the benefit manager device, pharmacy claims data to determine whether past claims adjudication data is associated with the controlled substance identifier, the past claims adjudication data associated with the controlled substance identifier also does not include the patient identification information;

evaluate, on the benefit manager device, the prescription request to determine whether the past claims adjudication data associated with the controlled substance identifier indicates that the prescription drug has been dispensed in a claim associated with the controlled substance identifier within a predetermined time of the prescription request;

generate, on the benefit manager device, a notification based on evaluation of the prescription request; and

transmit the notification from the benefit manager device via the network to at least one of the pharmacy device and the prescriber device, the notification indicating whether to dispense or not dispense the prescription drug; and

cause a pharmacy to dispense the prescription drug when the notification indicates to dispense the prescription drug.