Prospective management process for medical benefit prescriptions
First Claim
1. A method for authorizing and dispensing drugs, the method comprising:
- providing a database of patient eligibility criteria for drugs, the patient eligibility criteria associated with a plurality of health plans, and the database including patient identifying information associated with said health plans;
interactively receiving an input from a user, the input including a prior authorization request including an identification of a particular patient and a selection of a drug, the input further including a choice of a specialty pharmacy;
determining automatically by a data processor, based on the prior authorization request, a health plan corresponding with said identified patient in said database, and evaluating, automatically by the data processor, said patient eligibility criteria for said selected drug to determine whether said identified patient is eligible for the drug according to the automatically determined corresponding health plan;
providing automatically, by the data processor, in response to the evaluating of said patient eligibility criteria for the corresponding health plan based on the prior authorization request, an authorization code to said user corresponding with said selected drug and said identified patient;
receiving automatically, by the data processor, a pharmacy dispensing report from said chosen specialty pharmacy, wherein said pharmacy dispensing report is associated with said authorization code and provides a pharmacy confirmation that said selected drug was dispensed to at least one of a healthcare provider and said identified patient;
receiving automatically, by the data processor, a medical claims report from said health plan, wherein said medical claims report is associated with said authorization code and provides a medical confirmation that said selected drug was administered to said identified patient at the approved dosage; and
updating automatically, by the data processor, said database with utilization data corresponding to said pharmacy dispensing report and said medical claims report.
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Accused Products
Abstract
The present invention provides an interactive, electronic, knowledge-based ordering process for specialty/biotech pharmaceuticals (medically coded drugs) which results in less waste, improved procedural efficiencies, and greater cost savings than the current ordering systems. The knowledge-base of the system is based on the health plan'"'"'s clinical policies as well as the status of the patient and their entitled benefits with the health plan, and it is applied in an interactive manner through a web-enabled system which provides a real-time, prospective examination and control over requests for authorization to dispense the medically coded drugs. The system also includes a feedback loop from the specialty pharmacies to provide information on the medicines that have actually been dispensed. The system also provides to the patient, educational material and adherence reminders to affect therapeutic outcomes.
21 Citations
25 Claims
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1. A method for authorizing and dispensing drugs, the method comprising:
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providing a database of patient eligibility criteria for drugs, the patient eligibility criteria associated with a plurality of health plans, and the database including patient identifying information associated with said health plans; interactively receiving an input from a user, the input including a prior authorization request including an identification of a particular patient and a selection of a drug, the input further including a choice of a specialty pharmacy; determining automatically by a data processor, based on the prior authorization request, a health plan corresponding with said identified patient in said database, and evaluating, automatically by the data processor, said patient eligibility criteria for said selected drug to determine whether said identified patient is eligible for the drug according to the automatically determined corresponding health plan; providing automatically, by the data processor, in response to the evaluating of said patient eligibility criteria for the corresponding health plan based on the prior authorization request, an authorization code to said user corresponding with said selected drug and said identified patient; receiving automatically, by the data processor, a pharmacy dispensing report from said chosen specialty pharmacy, wherein said pharmacy dispensing report is associated with said authorization code and provides a pharmacy confirmation that said selected drug was dispensed to at least one of a healthcare provider and said identified patient; receiving automatically, by the data processor, a medical claims report from said health plan, wherein said medical claims report is associated with said authorization code and provides a medical confirmation that said selected drug was administered to said identified patient at the approved dosage; and updating automatically, by the data processor, said database with utilization data corresponding to said pharmacy dispensing report and said medical claims report. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 18, 19, 20)
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15. A method for authorizing and dispensing drugs, the method comprising:
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providing a database of patient eligibility criteria for drugs, the patient eligibility criteria associated with a plurality of health plans, and the database including patient identifying information associated with said health plans; receiving automatically periodic data feeds from said health plans, wherein said data feeds comprise eligibility data sets with health plan criteria and patients associated therewith; automatically integrating said health plan criteria from said periodic data feeds into said patient eligibility criteria in said database and updating said patient eligibility criteria in said database with said health plan criteria from said periodic data feeds; receiving a login request from a healthcare provider; verifying said login request is from a healthcare provider with rights to access at least certain drug data and health plan data in said database; displaying an interface screen having a plurality of data fields in which said healthcare provider provides patient identifying information and having lists of said drugs; interactively receiving an input from said healthcare provider, wherein said input comprises information identifying a patient and selecting a drug; automatically completing a plurality of said data fields with information from said database based on said healthcare provider input; receiving a prior authorization request corresponding to said identified patient and said selected drug for a defined therapy criterion, wherein said therapy criterion is at least one of a duration period and a dosage level; determining automatically by a data processor, based on the prior authorization request, a health plan corresponding with said identified patient in said database; evaluating automatically by the data processor, said patient eligibility criteria for said selected drug to determine whether said identified patient is eligible for the drug according to the corresponding automatically determined health plan; assigning, in response to the receiving of the prior authorization request and upon the verifying that said identified patient satisfies said patient eligibility criteria, an authorization code to said prior authorization request, wherein said authorization code comprises an authentication code as a unique transaction identifier between said healthcare provider and said identified patient for said selected drug and said defined therapy criteria; transmitting electronically to said patient a Drug Monograph, relevant messaging about a prescribed therapy, and calendar reminders about medication adherence; receiving a pharmacy dispensing report associated with said authorization code, wherein said dispensing report comprises a pharmacy confirmation from a specialty pharmacy indicating that said selected drug associated with said authorization code was dispensed to said healthcare provider; receiving a medical claims report associated with said authorization code, wherein said claims report comprises a medical confirmation from said healthcare provider indicating that said selected drug associated with said authorization code was administered to said identified patient; automatically updating said database with utilization data corresponding to said pharmacy dispensing report and said medical claims report; accumulating said utilization data with a plurality of utilization data from a plurality of pharmacy dispensing reports and a plurality of medical claims reports associated with a plurality of respective authorization codes; preparing a utilization report from said accumulated data; and reconciling rebate amounts. - View Dependent Claims (16, 21, 22)
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17. A method for authorizing and dispensing drugs, the method comprising:
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providing a database of patient eligibility criteria for drugs, the patient eligibility criteria associated with a health plan, and the database including patient identifying information associated with said eligibility data; receiving a login request from a user, wherein said user has an authorization from a healthcare provider; displaying an interface screen having a plurality of data fields configured to receive from said user patient identifying information and having lists of said drugs; interactively receiving, from said user, input comprising a request for prior authorization including an identification of a patient, a selection of a drug, and a choice of a specialty pharmacy; determining automatically by a data processor, based on the prior authorization request, a health plan corresponding with said identified patient in said database; evaluating automatically by the data processor, said patient eligibility criteria for said selected drug to determine whether said identified patient is eligible for the drug according to the corresponding automatically determined health plan; providing automatically, by the data processor, according to the evaluating of the patient eligibility criteria, an authorization code to said user for said selected drug and said identified patient; transmitting automatically, by the data processor, electronically to said patient a Drug Monograph, relevant messaging about a prescribed therapy, and a calendar reminder about medication adherence; receiving automatically, by the data processor, a pharmacy dispensing report from said chosen specialty pharmacy, wherein said pharmacy dispensing report is associated with said authorization code and provides a pharmacy confirmation that said selected drug was dispensed to said healthcare provider; receiving automatically, by the data processor, a medical claims report from said healthcare provider, wherein said medical claims report is associated with said authorization code and provides a medical confirmation that said selected drug was administered to said identified patient; and updating automatically, by the data processor, said database with utilization data corresponding to said pharmacy dispensing report and said medical claims report. - View Dependent Claims (23, 24, 25)
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Specification