Methods and systems for maintaining pharmacy provider networks

• US 10,373,255 B1
• Filed: 02/28/2013
• Issued: 08/06/2019
• Est. Priority Date: 02/28/2012
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Inventors: Cedergreen, Jacob Jon
• Primary Examiner(s): Paulson, Sheetal R
• Application Number:
  US13/780,073
• Time in Patent Office: 2,350 Days
• Field of Search: 705 2- 3
• CPC Class Codes: G06Q 40/08 Insurance
• 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

Abstract

Methods and systems for maintaining pharmacy provider networks are described. In one embodiment, claims adjudication data associated with a member and a prescribed drug is accessed. The prescribed drug associated with the member is classified as one of an acute medication and a maintenance medication. A pharmacy provider network is associated with the prescribed drug based on, at least in part, classifying the prescribed drug. It is determined if a pharmacy associated with the claims adjudication data is included within the pharmacy provider network associated with the prescribed drug. A pharmacy claim may be adjudicated for the prescribed drug based on the claim and the pharmacy provider network. Additional methods and systems are disclosed.

Claims

1. A method for communicating over a network to fill a prescription comprising:

retrieving via electronic communication from a memory, on a processor of a pharmacy benefit manager, the memory being remote from the processor, claims adjudication data associated with a member and a prescribed drug stored in the memory;

determining, on the processor of the pharmacy benefit manager, whether a number of available fills of the prescribed drug exceeds an acute medication threshold number of available fills that is variable and remotely selectable, wherein the acute medication threshold number is stored in a remote database and set in a pharmacy benefit provided by a client in a prescription drug plan to the member;

classifying, on the processor of the pharmacy benefit manager, the prescribed drug associated with the member as one of an acute medication and a maintenance medication based on the determination of whether the number of available fills of the prescribed drug exceeded the acute medication threshold number of available fills;

associating, on the processor, the prescribed drug with a type of pharmacy provider network based on classification of the prescribed drug, the type of pharmacy provider network being divided into two distinct subsets of an acute medication pharmacy provider network or a maintenance medication pharmacy provider network for the acute medication and the maintenance medication, respectively;

determining, on the processor, whether a pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network associated with the prescribed drug;

adjudicating, on the processor, a pharmacy claim for the prescribed drug through the pharmacy based on the pharmacy claim, the adjudication data and a determination of whether the pharmacy is included within the type of pharmacy provider network;

transmitting, from the processor over a network, an adjudication response from adjudication based adjudicating the pharmacy claim;

receiving, at a pharmacy device of the pharmacy at the acute medication pharmacy provider network or the maintenance medication pharmacy provider network that is associated with the prescription, the adjudication response;

authorizing a filling of the prescription for the member at the pharmacy after receipt of the adjudication response associated with the member; and

filling the prescription at the pharmacy after receipt of the adjudication response.

2. The method of claim 1, wherein accessing the claims adjudication data includes receiving an adjudication request from a pharmacy relative to the prescribed drug for the member.

3. The method of claim 1, wherein accessing the claims adjudication data includes accessing historical claims adjudication data for the member.

4. The method of claim 1, wherein classifying the prescribed drug comprises:

analyzing the claims adjudication data to determine one or more of a drug attribute and a fill attribute associated with the prescribed drug.

5. The method of claim 1, wherein classifying the prescribed drug comprises:

identifying one of a drug identity, a drug type, and a drug category.

6. The method of claim 1, wherein classifying the prescribed drug comprises:

determining that a number of fill requests of the prescribed drug exceeds an acute medication threshold number of fill requests.

7. The method of claim 6, wherein the acute medication threshold number of fill requests is three or greater;

and

wherein adjudicating includes transitioning the prescription from the acute medication pharmacy provider network and the maintenance medication pharmacy provider network when the acute medication threshold number is exceeded and filling the prescription using the maintenance medication pharmacy provider network with a different member benefit than a member benefit at the acute medication pharmacy provider network.

8. The method of claim 1, further comprising:

associating a first set member benefits with the prescribed drug for the acute medication pharmacy provider network; and

associating a second set of member benefits with the prescribed drug for the maintenance medication pharmacy provider network.

9. The method of claim 1, wherein accessing the claims adjudication data includes accessing historical claims adjudication data for the member.

10. The method of claim 1, wherein the acute medication pharmacy provider network includes specifically identified pharmacies including a retail pharmacy and wherein the maintenance medication pharmacy provider network includes specifically identified pharmacies including a retail pharmacy and a mail-order pharmacy.

11. The method of claim 1, further comprising transmitting a message to the member that the prescription must be filled at the pharmacy within the type of pharmacy provider network associated with the prescribed drug.

12. A non-transitory machine-readable medium storing instructions for filling a prescription over a network, which, when executed by one or more processors, cause the one or more processors to:

selecting a variable number for an acute medication threshold number of available fills for each drug available in the network;

access claims adjudication data associated with a member and a prescribed drug;

determine whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills using the claims adjudication data;

classify the prescribed drug associated with the member as one of an acute medication and a maintenance medication based on the determination of whether the number of available fills of the prescribed drug exceeded the acute medication threshold number of available fills;

associate the prescribed drug with a type of pharmacy provider network based on classification of the prescribed drug, the type of pharmacy provider network being an acute medication pharmacy provider network or a maintenance medication pharmacy provider network;

determine whether a pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network associated with the prescribed drug;

adjudicate a pharmacy claim for the prescribed drug through the pharmacy based on the pharmacy claim and a determination of whether the pharmacy is included within the type of pharmacy provider network;

transmit, from the processor over a network, an adjudication response from adjudication based adjudicating the pharmacy claim; and

receive, at a pharmacy device of the pharmacy, the adjudication response; and

authorizing a filling of the prescription for the member at the pharmacy after receipt of the adjudication response associated with the member to execute a physical filling of the prescription for the member at the pharmacy.

13. The non-transitory machine-readable medium of claim 12, wherein accessing the claims adjudication data includes receiving an adjudication request from a pharmacy relative to the prescribed drug for the member.

14. The non-transitory machine-readable medium of claim 12, wherein classifying the prescribed drug comprises:

analyzing the claims adjudication data to determine one or more of a drug attribute and a fill attribute associated with the prescribed drug.

15. The non-transitory machine-readable medium of claim 12, wherein classifying the prescribed drug comprises:

identifying one of a drug identity, a drug type, and a drug category.

16. The non-transitory machine-readable medium of claim 12, wherein classifying the prescribed drug comprises:

determining that a number of fill requests of the prescribed drug exceeds an acute medication threshold number of fill requests.

17. The non-transitory machine-readable medium of claim 12, wherein the instructions, when executed by the one or more processors, further cause the one or more processors to:

associate a first set member benefits with the prescribed drug for the acute medication pharmacy provider network; and

associate a second set of member benefits with the prescribed drug for the maintenance medication pharmacy provider network.

18. A method for filling a prescription comprising:

receiving, on a processor, a pharmacy claim to adjudicate, the pharmacy claim associated with a member and a prescribed drug;

remotely selecting an acute medication threshold number of available fills, which is a selectable variable;

transmitting the acute medication threshold number of available fills to the processor;

classifying, on the processor, the prescribed drug associated with the member as a maintenance medication based on a determination of whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills;

determining, on the processor, that a pharmacy associated with a request to adjudicate the pharmacy claim is included within an acute medication pharmacy provider network; and

transmitting, on the processor, a warning that a modified set of member benefits are associated with filling the prescribed drug at the pharmacy based on classification of the prescribed drug as a maintenance medication and a determination that the pharmacy is included within the acute medication pharmacy provider network;

transmitting, from the processor over a network, an adjudication response from adjudication based adjudicating the pharmacy claim;

receiving, at a pharmacy device of the pharmacy, the adjudication response;

authorizing a filling of the prescription for the member at the pharmacy after receipt of the adjudication response associated with the member; and

filling the prescription at the pharmacy after receipt of the adjudication response.

19. The method of claim 18, wherein the modified set of member benefits include an elevated member co-pay.

20. The method of claim 18, wherein determining includes transitioning the prescription from the acute medication pharmacy provider network and a maintenance medication pharmacy provider network when the acute medication threshold number is exceeded and filling the prescription using the maintenance medication pharmacy provider network with a different member benefit than a member benefit at the acute medication pharmacy provider network.

21. A pharmacy system for transmitting a prescription comprising:

a plurality of pharmacies including a first pharmacy provider device in an acute medication pharmacy provider network and a second pharmacy provider device in a maintenance medication pharmacy provider network;

a manager device to select, from a variable, an acute medication threshold number of available fills and to transmit the acute medication threshold number of available fills for storage in a database on the memory; and

an adjudicator subsystem including;

a data access device to retrieve, via electronic communication, claims adjudication data associated with a member and a prescribed drug stored in a memory;

an analysis device to determine whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills that is stored in a database on the memory;

a classification device to classify the prescribed drug associated with the member as one of an acute medication and a maintenance medication based on a determination of whether the number of available fills of the prescribed drug exceeded the acute medication threshold number of available fills;

a network determination device to associate the prescribed drug with a type of pharmacy provider network based on classification of the prescribed drug, the type of pharmacy provider network being the acute medication pharmacy provider network or the maintenance medication pharmacy provider network, wherein the network determination device is to determine whether a pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network associated with the prescribed drug;

an adjudication device to adjudicate a pharmacy claim for the prescribed drug through the pharmacy based on the pharmacy claim and a determination of whether the pharmacy is included within the type of pharmacy provider network; and

a transmission device to transmit, over an electronic communication network, an adjudication response from the adjudication device based adjudicating the pharmacy claim to at least one of the plurality of pharmacies of either the first pharmacy provider device or the second pharmacy provider device, but not both the first pharmacy provider device and the second pharmacy provider device;

wherein the at least one of the plurality of pharmacies of either the first pharmacy provider device or the second pharmacy provider device is to receive, at a pharmacy device, the adjudication response with an authorization for filling of the prescription for the member; and

wherein the at least one of the plurality of pharmacies fills the prescription upon receipt of the adjudication response with an authorization for filling of the prescription.

22. The system of claim 21, wherein the adjudicator subsystem is configured to use criterion for establishing a prescribed drug as an acute medication to be filled in the acute medication pharmacy provider network.

23. The system of claim 22, further comprising a prescriber device to send prescription data over a network without a determination of whether the prescribed drug is an acute drug or a maintenance drug.