Pharmacy benefit management system and method of using same

• US 6,195,612 B1
• Filed: 01/05/1998
• Issued: 02/27/2001
• Est. Priority Date: 01/05/1998
• Status: Expired due to Term

• Current Assignee: Tama L. Pack-Harris
• Original Assignee: Tama L. Pack-Harris
• Inventors: Pack-Harris, Tama L.
• Primary Examiner(s): Kemper, Melanie A.
• Application Number:
  US09/003,082
• Time in Patent Office: 1,149 Days
• Field of Search: 702/2, 702/3
• US Class Current: 702/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 99/00 Subject matter not provided for in other groups of this subclass
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients

Abstract

The pharmacy benefit management system includes a pharmacy computer for generating pharmacy claim information based on pharmacy activity of a medical group. A health plan computer is responsive to the pharmacy claim information for generating pharmacy activity information for the medical group. A medical group computer receives the pharmacy activity information from the health plan computer and stores the pharmacy activity information. The pharmacy activity information is processed to generate utilization information to enable the medical group to monitor the pharmacy activity.

Claims

1. A pharmacy benefit management system for monitoring the prescription activity of a medical group, the medical group contracting with a plurality of health plans, comprising:

pharmacy computer means for generating pharmacy claim information including prescribed drug information corresponding to the prescription activity;

a plurality of health plan computer means, each one associated with a different one of said plurality of health plans and each one being responsive to said pharmacy claim information for processing said prescribed drug information to generate medical group prescription information corresponding to the medical group;

medical group computer means configured for receiving and storing said medical group prescription information to facilitate an evaluation of the prescription activity;

means for transferring the medical group prescription information from all of said health plan computer means to the medical group computer means;

means for receiving at the medical group computer means medical group prescription information for the plurality of health plans;

means for determining the actual cost to the medical group for prescription drugs prescribed by doctors in the medical group, the means for determining being responsive to the prescription information for the plurality of health plans;

means for storing capitation benefits received from the plurality of health plans in said medical group computer means;

means for comparing the determined actual cost and said stored capitation benefits as received from the plurality of health plans; and

report means for processing said stored medical group prescription information to generate utilization information indicative of the prescription activity for enabling the medical group to monitor the prescription activity to determine if the prescription activity should be modified.

2. A system according to claim 1, further including pharmacy benefit computer means for accumulating said pharmacy claim information and for transmitting said accumulated pharmacy claim information to said health plan computer means.

3. A system according to claim 1, wherein said pharmacy computer means includes a plurality of pharmacy computers corresponding to a plurality of pharmacies, each one of said pharmacy computers generating pharmacy claim information including prescribed drug information corresponding to prescriptions received at respective ones of said pharmacies.

4. A system according to claim 1, wherein said health plan computer means includes a plurality of health plan computers corresponding to the plurality of health care plan organizations, each one of said health plan computers processes said prescribed drug information corresponding to a respective one of said health care plan organizations to generate said medical group prescription information corresponding to the medical group and associated with said respective one of said health care plan organizations.

5. A system according to claim 1, wherein said medical group computer means further stores physician information for physicians associated with the medical group.

6. A system according to claim 5, wherein said report means includes physician report means for generating physician reports.

7. A system according to claim 6, wherein said physician reports indicate particular drugs prescribed by said physicians.

8. A system according to claim 5, wherein said report means includes medical group report means for generating medical group reports.

9. A system according to claim 8, wherein said medical group reports indicate particular drugs prescribed by said physicians.

10. A method of monitoring the prescription activity of a medical group, the medical group having contracts with one or more health plans that provide prescription drug capitation, comprising:

collecting pharmacy claim information from a plurality of pharmacies, the pharmacy claim information including prescribed drug information, prescribing doctor information, and health plan identification, corresponding to the prescription activity;

processing said pharmacy claim information to generate medical group prescription information corresponding to the medical group, the medical prescription information selected for the contracted health plans;

transferring the medical group prescription information to a medical group computer means;

determining from the medical group prescription information actual costs to the medical group for prescription drugs prescribed by doctors associated with the medical group, an actual cost being determined separately for each of the contracted health plans;

comparing the determined actual costs of prescription drugs to capitation benefits received from the contracted health care plans;

evaluating the adequacy of the capitation received from the contracted health care plans;

receiving and storing said medical group prescription information to facilitate an evaluation of the prescription activity;

processing said stored medical group prescription information to generate utilization information indicative of the prescription activity for enabling the medical group to monitor the prescription activity to determine if the prescription activity should be modified; and

health plan computers corresponding to a plurality of health care plan organizations, and generating said medical group prescription information at each one of said health plan computes corresponding to the medical group and associated with said respective one of said health care plan organizations.

11. A method according to claim 10, further including accumulating said pharmacy claim information and transmitting said accumulated pharmacy claim information.

12. A method according to claim 10, further including using a plurality of pharmacy computers corresponding to the plurality of pharmacies, and generating pharmacy claim information including prescribed drug information corresponding to prescriptions received at respective ones of said pharmacies.

13. A method according to claim 10, further including storing physician information for physicians associated with the medical group.

14. A method according to claim 13, further including generating physician reports.

15. A method according to claim 14, further including indicating particular drugs prescribed by said physicians.

16. A method according to claim 13, further including generating medical group reports.

17. A method according to claim 16, further including indicating particular drugs prescribed by said physicians.