Systems and methods for alerting pharmacies of formulary alternatives

• US 20060271402A1
• Filed: 05/26/2006
• Published: 11/30/2006
• Est. Priority Date: 05/27/2005
• Status: Active Grant

• Current Assignee: Mckesson Technologies Incorporated (UnitedHealth Group Incorporated)
• Original Assignee: Per-Se Technologies Incorporated (McKesson Corp.)
• Inventors: Williams, Warren K., Rowe, James C. III
• Granted Patent: US 8,321,283 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 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, systems and computer program products alert pharmacies of formulary alternatives. A claim generated by a provider and including at least one drug is received, where the claim is directed to a payer recipient. The claim is reviewed to identify the at least one drug. The at least one drug is then compared to a pre-established formulary alternative table, which may be created or managed, at least in part, by the payer recipient. A preferred drug alternative may then be forwarded to the provider when the at least one drug has a match in the pre-established formulary alternative table.

Claims

1. A method of alerting pharmacies of formulary alternatives, comprising:

receiving a claim generated by a provider, wherein the claim comprises at least one drug, and wherein the claim is directed to a payer recipient;

reviewing the claim to identify the at least one drug;

comparing the at least one drug to a pre-established formulary alternative table established, at least in part, by the payer recipient; and

forwarding a preferred drug alternative to the provider when the at least one drug has a match in the pre-established formulary alternative table.

2. The method of claim 1, wherein the provider comprises a pharmacy.

3. The method of claim 1, wherein the claim identifies a patient associated with the payer recipient.

4. The method of claim 1, wherein forwarding a preferred drug alternative to the provider comprises forwarding the preferred drug alternative to the provider via an alert that may be accepted or declined by the provider.

5. The method of claim 1, further comprising receiving a new claim from the provider for the preferred drug alternative.

6. The method of claim 5, further comprising forwarding the new claim to the payer recipient.

7. The method of claim 6, further comprising:

receiving a response from the payer recipient subsequent to the payer recipient'"'"'s adjudication of the new claim; and

instructing the provider that the new claim is approved.

8. The method of claim 1, wherein the pre-established formulary alternative table comprises formulary information or drug-specific tables.

9. The method of claim 1, wherein the claim comprises content defined by the payer recipient.

19. The system of claim 1, wherein the pre-established formulary alternative table comprises formulary information or drug-specific tables.

20. The system of claim 1, wherein the claim comprises content defined by the payer recipient.

10. A system of alerting pharmacies of formulary alternatives, comprising:

an intermediary server, in communication with a provider, wherein the intermediary server is operable to;

receive a claim generated by a provider, where the claim comprises at least one drug, and where the claim is directed to a payer recipient;

review the claim to identify the at least one drug;

compare the at least one drug to a pre-established formulary alternative table established, at least in part, by the payer recipient; and

forward a preferred drug alternative to the provider when the at least one drug has a match in the pre-established formulary alternative table.

11. The system of claim 10, wherein the provider comprises a pharmacy or a pharmacy practice management system.

12. The system of claim 10, wherein the claim identifies a patient associated with the payer recipient.

13. The system of claim 10, wherein the intermediary server is local to the provider.

14. The system of claim 10, wherein the intermediary server is in communication with the provider via at least one network.

15. The system of claim 10, wherein the intermediary server is further operable to forwarding the preferred drug alternative to the provider via an alert that may be accepted or declined by the provider.

16. The system of claim 10, wherein intermediary server is further operable to receive a new claim from the provider for the preferred drug alternative.

17. The system of claim 16, wherein the intermediary server is further operable to transmit the new claim to the payer recipient.

18. The system of claim 17, wherein the intermediary server is further operable to:

receive a response from the payer recipient subsequent to the payer recipient'"'"'s adjudication of the new claim; and

instruct the provider that the new claim is approved.