PRESCRIPTION DRUG PRIOR AUTHORIZATION SYSTEM AND METHOD
First Claim
1. A computerized method for processing prior authorization drug requests comprising:
- (a) receiving at a rules database server a prior authorization drug request, said request comprising identify information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member;
(b) logging said request in a drug request transaction computer system;
(c) applying authorization criteria to said drug request for approving or denying dispensing of said drug to said member according to said pharmacy benefits plan for said member and said identifying information for said member; and
(d) forwarding a prior authorization decision for said drug request from said rules database server to a pharmacy benefits manager computer;
(e) wherein said drug is dispensed to said member according to said prior authorization decision received at said pharmacy benefits manager from said rules database server.
1 Assignment
0 Petitions
Accused Products
Abstract
An online application for approving prior authorization requests for prescription drugs. The application is used by pharmacy benefits providers, physicians, and pharmacies to request prior authorizations for drugs and to receive approvals automatically if a requested drug meets authorization criteria. The online application is accessible through a group pharmacy benefits provider portal on a web site. Requests are processed through a pharmacy benefits manager computer that determines whether prior authorization is required and through a pharmacy benefits provider computer when the pharmacy benefits manager computer determines that prior authorization is required. Requests that meet certain authorization criteria are approved automatically. Requests that cannot be approved automatically are submitted for review by a clinical pharmacy review division that access requests through a drug request transaction computer.
29 Citations
17 Claims
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1. A computerized method for processing prior authorization drug requests comprising:
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(a) receiving at a rules database server a prior authorization drug request, said request comprising identify information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member; (b) logging said request in a drug request transaction computer system; (c) applying authorization criteria to said drug request for approving or denying dispensing of said drug to said member according to said pharmacy benefits plan for said member and said identifying information for said member; and (d) forwarding a prior authorization decision for said drug request from said rules database server to a pharmacy benefits manager computer; (e) wherein said drug is dispensed to said member according to said prior authorization decision received at said pharmacy benefits manager from said rules database server. - View Dependent Claims (2, 3, 4, 5, 6, 7, 11, 12, 16, 17)
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8. A computerized method for processing prior authorization drug requests comprising:
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(a) receiving at a pharmacy benefits manager computer a request for a prescription drug to be dispensed to a member covered by a pharmacy benefits plan, said request comprising member identification information and drug identifying information; (b) determining whether said prescription drug requires prior authorization in advance of dispensing said prescription drug to said member by completing a drug utilization review; (c) receiving said request at a rules database server to complete a prior authorization process if said prescription drug requires prior authorization, said prior authorization process at said rules database server comprising; (i) applying authorization criteria to said prescription drug; (ii) forwarding a prior authorization approval to said pharmacy benefits manager computer if said prescription drug meets said authorization criteria; and (d) approving said prescription drug at said pharmacy benefits manager computer if said prescription drug does not require prior authorization. - View Dependent Claims (9, 10, 13, 14, 15)
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Specification