Apparatus and method for constructing formularies

• US 20040006491A1
• Filed: 01/07/2003
• Published: 01/08/2004
• Est. Priority Date: 01/22/2002
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Brown, Kenneth J., Daniel, Roselin, Stettin, Glen D., Tobin, William D.
• Granted Patent: US 7,490,047 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

An system for constructing formularies is disclosed. The system includes a central computer system and at least one additional computer. The central computer system compiles a list of various pharmaceutical products and sort them into different categories. Formularies are then created by selecting individual products or categories of products that will be covered. When prescription claims are received, coverage is either accepted or denied based on whether the products in the prescription claims are covered by the formulary.

Claims

1. A method of constructing a formulary comprising the steps:

compiling a list of pharmaceutical products;

sorting the pharmaceutical products into at least one category based on predetermined relational characteristics; and

selecting a plurality of pharmaceutical products from the at least one category, the selected pharmaceutical products to be supported by the formulary.

2. The method of claim 1, further comprising a step of establishing global rules to be applied to the formulary when performing the step of selecting.

3. The method of claim 1, further comprising a step of defining dosage limitations for the pharmaceutical products supported by the formulary.

4. The method of claim 3, wherein the dosage limitations are selected from the group of doses consisting of regular strength, extra strength, and time release.

5. The method of claim 1, further comprising a step of defining delivery limitations for the pharmaceutical products supported by the formulary.

6. The method of claim 5, wherein in the delivery limitations are selected from the group of delivery methods consisting of topical, oral, and injectionable.

7. The method of claim 1, further comprising a step of:

defining sixteen categories; and

wherein the step of sorting comprises sorting the pharmaceutical products into the sixteen defined categories based on predetermined relational characteristics.

8. The method of claim 1, further comprising a step of defining inclusion rules that dictate optional criteria for accepting coverage of non-formulary pharmaceutical products.

9. The method of claim 8, wherein the step of defining inclusion rules includes a step of defining a copay value that is greater than a formulary copay.

10. The method of claim 8, wherein the step of defining inclusion rules includes a step of defining pre-authorization procedures for accepting coverage of the non-formulary pharmaceuticals.

11. The method of claim 8, wherein the step of defining inclusion rules includes a step of suggesting at least one preferred alternative pharmaceutical product that would be covered by the prescription formulary.

12. The method of claim 1, further comprising a step of creating reports that compare two or more formularies.

13. The method of claim 1, wherein:

the at least one category includes at least one subcategory; and

the step of sorting comprises a step of sorting the pharmaceutical products into the at least one category and the at least one subcategory.

14. The method of claim 13, wherein the step of selecting comprises the steps:

selecting a category; and

automatically including all pharmaceutical products contained in the selected category and all pharmaceutical products contained in the at least one subcategory contained in the selected category.

15. The method of claim 13, further comprising a step of indicating a selection status for pharmaceutical products in the at least one category.

16. The method of claim 15, wherein the step of indicating comprises a step of indicating whether all pharmaceutical products in the at least one category have been selected or have not been selected, or indicating whether only some of the pharmaceutical products have been selected.

17. The method claim 13, further comprising a step of indicating whether each at least one category contains subcategories.

18. The method of claim 13, further comprising a step of indicating whether each at least one subcategory contains additional subcategories.

19. The method of claim 1, wherein the step of selecting includes a step of selecting a plurality of pharmaceutical products over an electronic network.

20. The method of claim 1, further comprising a step of linking pharmaceutical products to information sources.

21. The method of claim 20, wherein the step of linking includes a step of creating a hypertext link to the information sources.

22. The method of claim 20, wherein the information sources are remotely located.

23. A method of remotely establishing requirements for implementing a formulary, comprising the steps:

accessing, over an electronic network, a computer system containing pharmaceutical products sorted into at least one category based on predetermined relational links; and

selecting a plurality of pharmaceutical products to be supported by the formulary.

24. The method of claim 23, wherein each category includes at least one subcategory;

and the pharmaceutical products are sorted into the at least one category and the at least one subcategory, and wherein the step of selecting comprises the steps;

selecting a category; and

automatically including all pharmaceutical products contained in the selected category and all pharmaceutical products contained in the at least one subcategory contained in the selected category.

25. The method of claim 23, further comprising a-step of establishing global rules to be applied to the formulary when accepting and rejecting prescription claims.

26. The method of claim 23, further comprising a step of defining dosage limitations for the pharmaceutical products supported by the formulary.

27. The method of claim 23, further comprising a step of specifying delivery limitations for the pharmaceutical products supported by the formulary.

28. The method of claim 23, further comprising a step of defining inclusion rules that dictate optional criteria for accepting coverage of non-formulary pharmaceutical products.

29. The method of claim 23, further comprising a step of providing links to information sources for one or more pharmaceutical products.

30. A method of implementing a formulary for processing prescription claims, comprising the steps:

compiling a list of pharmaceutical products;

sorting the pharmaceutical products into at least one category based on predetermined relational characteristics;

providing access to a computer system containing formulary information to a user; and

receiving selections of pharmaceutical products to be supported by the formulary from the user.

31. The method of claim 30, further comprising the steps:

receiving prescription claims for coverage of a prescribed pharmaceutical product;

accepting coverage for the prescription claims based on whether the prescribed pharmaceutical products are supported by the formulary; and

rejecting coverage for the prescription claims based on whether the prescribed pharmaceutical products are is not supported by the formulary.

32. The method of claim 31, further comprising a step of creating a model formulary based at least in part on prescription claims that have been accepted for coverage and prescription claims that have been rejected for coverage.

33. The method of claim 30, further comprising the steps:

automatically updating the list of pharmaceutical products at predetermined intervals to include newly released pharmaceutical products; and

sorting the newly released pharmaceutical products into the at least one categories based on the predetermined relational characteristics.

34. The method of claim 30, wherein:

the at least one category includes at least one subcategory; and

the step of sorting comprises a step of sorting the pharmaceutical products into the at least one category and the at least one subcategory.

35. The method of claim 34, wherein the step of receiving selections comprises the steps:

receiving a selection for a category; and

automatically including all pharmaceutical products contained in the selected category and all pharmaceutical products contained in the at least one subcategory contained in the selected category.

36. The method of claim 30, further comprising a step of indicating a selection status for pharmaceutical products in the at least one category.

37. The method of claim 30, further comprising a step of linking pharmaceutical products to information sources.

38. The method of claim 37, wherein the step of linking includes a step of creating a hypertext link to the information sources.

39. The method of claim 37, wherein the information sources are remotely located.

40. A method of implementing a formulary comprising the steps:

compiling a list of pharmaceutical products;

sorting the pharmaceutical products into at least one category based on predetermined relational characteristics;

selecting a plurality of pharmaceutical products from the at least one category, the selected pharmaceutical products to be supported by the formulary;

receiving a prescription claim for coverage of a prescribed pharmaceutical product;

accepting coverage for the prescription claim based on whether the prescribed pharmaceutical product is supported by the formulary; and

rejecting coverage for the prescription claim based on whether the prescribed pharmaceutical product is not supported by the formulary.

41. The method of claim 40, further comprising the steps:

collecting data pertaining to claims processing during implementation of the formulary; and

preparing a budgetary analysis for the cost of implementing the formulary, based at least in part on the number of prescription claims accepted for coverage and an associated coverage cost.

42. The method of claim 41, wherein a prescription claim has been rejected and further comprising the step of:

appealing rejection of the prescription claim, and

wherein the step of preparing is further performed based on a cost of processing the appeal.

43. The method of claim 40, further comprising a step of creating a model formulary based at least in part on prescription claims that have been accepted for coverage and prescription claims that have been rejected for coverage.

44. The method of claim 40, further comprising the steps:

automatically updating the list of pharmaceutical products at predetermined intervals to include newly released pharmaceutical products; and

sorting the newly released pharmaceutical products into the at least one categories based on the predetermined relational characteristics.

45. The method of claim 44, further comprising a step of automatically selecting newly released pharmaceutical products to be supported by the formulary, based at least in part on the categories where the newly released pharmaceutical products are sorted.

46. The method of claim 40, further comprising a step of establishing global rules to be applied to the formulary when performing the steps of selecting, accepting, and rejecting.

47. The method of claim 40, further comprising a step of linking pharmaceutical products to information sources.

48. The method of claim 47, wherein the step of linking includes a step of creating a hypertext link to the information sources.

49. The method of claim 47, wherein the information sources are remotely located.

50. A method of constructing a formulary comprising the steps:

compiling a list of pharmaceutical products including at least one of a drug, therapy, and prosthetic that may potentially be used to construct the formulary;

sorting the pharmaceutical products into at least one category indicative of at least one of treatment and therapy options based on predetermined relational characteristics between the pharmaceutical product and the at least one category; and

selecting the pharmaceutical products from the at least one category to be used in constructing the formulary responsive to predetermined criteria.

51. A system for constructing formularies, comprising:

a central computer;

at least one additional computer; and

a communication interface coupled to said central computer for establishing a communication channel with said at least one additional computer;

said central computer being configured to;

compile a list of pharmaceutical products,

sort the pharmaceutical products into at least one category based on predetermined relational characteristics, and

allow the at least one additional computer to select a plurality of pharmaceutical products from the at least one category, the selected pharmaceutical products to be supported by the formulary.

52. A system for implementing formularies, comprising:

a central computer;

at least one additional computer; and

a communication interface coupled to said central computer for establishing a communication channel with said at least one additional computer;

said central computer being configured to;

compile a list of pharmaceutical products,

sort the pharmaceutical products into at least one category based on predetermined relational characteristics,

allow the at least one additional computer to select a plurality of pharmaceutical products from the at least one category, the selected pharmaceutical products to be supported by the formulary,

receive a prescription claim for coverage of a prescribed pharmaceutical product,

accept coverage for the prescription claim based on whether the prescribed pharmaceutical product is supported by the formulary, and

reject coverage for the prescription claim based on whether the prescribed pharmaceutical product is not supported by the formulary.