Apparatus and method for constructing formularies

• US 7,490,047 B2
• Filed: 01/07/2003
• Issued: 02/10/2009
• 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.
• Primary Examiner(s): Gilligan; C Luke
• Assistant Examiner(s): NGUYEN, TRAN N
• Application Number:
  US10/337,366
• Publication Number:
  US 20040006491A1
• Time in Patent Office: 2,226 Days
• Field of Search: 705 2- 4
• 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

A 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 sorts them into different categories based on predetermined relational characteristics. The relational characteristics are based on therapeutic classifications of the pharmaceutical products, which in turn share these relational characteristics. Formularies are then created by selecting individual products and/or categories of products that the formularies would support. When prescription claims are received, coverage is either accepted or denied based on whether the products in die prescription claims are covered by the formulary.

Claims

1. A method of constructing a formulary, comprising:

(a) storing a plurality of pharmaceutical products in a computer;

(b) storing in the computer a plurality of pharmaceutical categories, wherein each pharmaceutical category comprises;

(i) a category definition based on predetermined relational characteristics shared by the plurality of pharmaceutical products;

(ii) a therapeutic description;

(c) sorting, by the computer, the plurality of pharmaceutical products into the appropriate pharmaceutical category based on each pharmaceutical product'"'"'s matching with individual category definitions and therapeutic descriptions for the respective pharmaceutical category;

(d) displaying, by the computer, the sorted plurality of pharmaceutical products, wherein each pharmaceutical product is classified into at least one pharmaceutical category,

(e) creating a plurality of base formularies, wherein each base formulary is created by;

(i) selecting on the computer at least one of the sorted pharmaceutical products for inclusion in the base formulary,

(ii) entering into the computer inclusion rules descriptive of the base formulary;

(iii) saving the base formulary in the computer,

(f) creating a new formulary by;

(i) defining desired inclusion rules comprising criteria for accepting coverage of non-formulary pharmaceutical products when present;

(ii) selecting at least one of the preexisting base formularies when the selected base formulary'"'"'s inclusion rules are substantially similar to the desired inclusion rules by;

(1) displaying to the user information for selection of the base formulary and respective inclusion rules;

(2) allowing the user to select using the computer the preexisting base formulary responsive to said prompting;

(iii) modifying the selected base formulary when additional pharmaceutical products are present by allowing the user to select on the computer the additional pharmaceutical products to be included into the new formulary;

(iv) saving when the selected base formulary is modified in the computer as the new formulary;

(g) adding the new formulary for use by the user to administer a pharmaceutical benefits plan for a plurality of members.

2. The method of claim 1, wherein the step of sorting comprises sorting the pharmaceutical products into sixteen defined categories based on predetermined relational characteristics.

3. The method of claim 2, wherein the sixteen categories are selected from a group comprising anti-infectives;

antineoplastic and immunosuppressant drugs;

autonomic and central nervous system drugs, neurology and psychiatry;

cardiovascular, hypertension and lipids;

dermatological and/or topical therapy;

ear, nose and throat medications;

endocrine and/or diabetes;

gastroenterology;

immunology, vaccines and biotechnology;

musculoskeletal and rheumatology;

obstetrics and gynecology;

ophthalmology;

respiratory, allergy, cough and cold;

urologicals;

vitamins, hematinics and electrolytes; and

diagnostics and miscellaneous agents.

4. The method of claim 3, further comprising a step of linking pharmaceutical products to information sources.

5. The method of claim 4, wherein the step of linking includes a step of creating a hypertext link to the information sources.

6. The method of claim 4, wherein the information sources are remotely located.

7. The method of claim 3, 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.

8. The method of claim 7, 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.

9. The method of claim 3, 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.

10. The method of claim 3, 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 pharmaceutical categories based on the predetermined relational characteristics.

11. The method of claim 3, wherein:

the at least one pharmaceutical 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.

12. The method of claim 3, wherein the step of creating a plurality of base formularies further 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.

13. The method of claim 3, further comprising a step of indicating a selection status for pharmaceutical products in the at least one category.

14. The method of claim 3, 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.

15. The method of claim 3, further comprising a step of establishing global rules to be applied to the formulary when performing the steps of selecting, accepting, and rejecting.

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

17. The method of claim 16, wherein the dosage limitations are selected from at least one of strength of the pharmaceutical products per dose and time release.

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

19. The method of claim 18, wherein in the delivery limitations are selected from the group of delivery methods consisting of topical, oral, and injectionable.

20. The method of claim 1, further comprising a step of indicating a selection status for pharmaceutical products in the at least one pharmaceutical category.

21. The method of claim 20, wherein the step of indicating comprises a step of indicating whether all pharmaceutical products in the at least one pharmaceutical category have been selected or have not been selected, or indicating whether only some of the pharmaceutical products have been selected.

22. The method claim 1, further comprising a step of indicating whether each of the at least one pharmaceutical category of the plurality of pharmaceutical categories contains subcategories.

23. The method of claim 22, further comprising a step of indicating whether each of the at least one subcategory contains additional subcategories.

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

25. The method of claim 24, wherein the step of linking includes a step of creating a hypertext link to the information sources.

26. The method of claim 1, wherein the step of selecting at least one of the sorted pharmaceutical products further comprises a step of establishing global rules to be applied to the formulary.

27. The method of claim 1, wherein the inclusion rules further defines a copay value that is greater than a formulary copay.

28. The method of claim 1, wherein the inclusion rules further defines pre-authorization procedures for accepting coverage of the non-formulary pharmaceuticals.

29. The method of claim 1, wherein the step of defining desired inclusion rules includes a step of suggesting at least one preferred alternative pharmaceutical product that would be covered by the prescription formulary.

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

31. The method of claim 1, wherein:

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

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

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

33. The method of claim 1, further comprising the step of preparing a budgetary analysis comprising cost for covering the pharmaceutical products provided by the formulary.

34. The method of claim 1, wherein the type of coverage is defined by a budgetary analysis.

35. The method of claim 1, wherein the type of coverage provides optimum coverage at low cost.

36. A method of constructing a formulary, comprising:

(a) storing a plurality of pharmaceutical products in a computer;

(b) storing in the computer a plurality of pharmaceutical categories, wherein each pharmaceutical category comprises;

(i) a category definition based on predetermined relational characteristics shared by the plurality of pharmaceutical products;

(ii) a therapeutic description;

(c) sorting, by the computer, the plurality of pharmaceutical products into the appropriate pharmaceutical category based on each pharmaceutical product'"'"'s matching with individual category definitions and therapeutic descriptions for the respective pharmaceutical category;

(d) displaying, by the computer, the sorted plurality of pharmaceutical products, wherein each pharmaceutical product is classified into at least one pharmaceutical category,

(e) creating a plurality of base formularies, wherein each base formulary is created by;

(i) selecting on the computer at least one of the sorted pharmaceutical products for inclusion in the base formulary,

(ii) entering into the computer inclusion rules descriptive of the base formulary;

(iii) saving the base formulary in the computer,

(f) updating the list of pharmaceutical products in at least one of the plurality of base formularies at predetermined intervals to include newly released pharmaceutical products;

(g) sorting the newly released pharmaceutical products into the at least one categories based on the predetermined relational characteristics;

(h) selecting additional released pharmaceutical products from the newly released pharmaceutical products to be supported by the at least one of the plurality of formularies, based at least in part on the categories where the newly released pharmaceutical products are sorted;

(i) receiving a prescription claim for coverage of a prescribed pharmaceutical product,

(j) accepting coverage for the prescription claim based on whether the prescribed pharmaceutical product is supported by at least one of the formularies, and

(k) rejecting coverage for the prescription claim based on whether the prescribed pharmaceutical product is not supported by the at least one of the formularies.