Method for conducting prescription drug co-payment plans

• US 7,657,437 B2
• Filed: 06/27/2003
• Issued: 02/02/2010
• Est. Priority Date: 06/27/2002
• Status: Active Grant

• Current Assignee: Omnicare Incorporated (CVS Health Corporation)
• Original Assignee: Omnicare Incorporated (CVS Health Corporation)
• Inventors: Kalies, Ralph F.
• Primary Examiner(s): Gilligan; C. Luke
• Assistant Examiner(s): RANGREJ, SHEETAL
• Application Number:
  US10/608,265
• Publication Number:
  US 20040073457A1
• Time in Patent Office: 2,412 Days
• Field of Search: 705 2- 3
• US Class Current: 705/1.1
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/00 Payment architectures, schemes or protocols apparatus for performing or posting payment transactions G07F7/08, G07F19/00; electronic cash registers G07G1/12
• CPC Class Codes: G06Q 20/02 involving a neutral party, e.g. certification authority, notary or trusted third party [TTP]
• CPC Class Codes: G06Q 20/28 Pre-payment schemes, e.g. "pay before"
• CPC Class Codes: G06Q 30/016 After-sales
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/65 stored on portable record carriers, e.g. on smartcards, RFID tags or CD
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients

Abstract

A credit card-based prescription benefits plan utilizes an electronic means for telecommunication to rapidly adjudicate prescription claims. The adjudication process includes a third-party claims processor interposed the pharmacy and the patient'"'"'s credit card clearinghouse to ensure that the subscriber receives all benefits available under the plan. The third-party claims processor may also provide patient counseling and advocacy by performing patient-specific drug regimen reviews to check for potential adverse drug reactions and drug interactions.

Claims

1. A method of providing prescription benefits to subscribers under a subscriber co-pay plan via an electronic communications network to ensure that the subscriber receives a discounted prescription price, the method comprising the steps of:

a) identifying a sponsor for a prescription benefits plan;

b) designing the prescription benefits plan to include a formulary of preferred medications, and to define prescription medications that are covered by the prescription benefits plan;

c) identifying at least one pharmacy that;

i) participates in the prescription benefits plan,

ii) receives prescriptions for medication and prescription benefit claims from subscribers, and

iii) fulfills the prescriptions for a discounted prescription price;

d) identifying at least one eligible subscriber having a valid credit or debit account with a creditor or institution and wishing to participate in the prescription benefits plan;

e) enrolling each eligible subscriber who wishes to participate in the prescription benefits plan and generating an electronic file for each of the eligible subscribers;

f) generating an eligibility profile for each subscriber and storing said eligibility profile in an electronic memory;

g) establishing a prescription benefits manager to administer the prescription benefits plan;

h) establishing a prescription claims processor that;

i) receives claims over the electronic communications network for prescription benefits from a participating pharmacy;

ii) adjudicates the claims in accordance with the subscriber'"'"'s eligibility profile; and

iii) upon approval of a claim, charges the subscriber'"'"'s credit or debit account for accepted claims via the electronic communications network, the amount of the charge being equal to the discounted price of the prescription minus a predetermined co-payment which is tendered by the subscriber to the pharmacy at the time of fulfilling the prescription;

i) making a first payment via the electronic communications network by the creditor to the prescription benefits manager, the first payment being equal to the amount charged to the subscriber'"'"'s account minus a first predetermined service fee to be retained by the creditor;

j) making a second payment via the electronic communications network by the prescription benefits manager to the pharmacy, the second payment being equal to a predetermined portion of the discounted prescription price; and

k) making a third payment via the electronic communication network by the prescription benefits manager to the claims processor, the third payment being equal to a second predetermined service fee, wherein the second payment and the third payment are funded by the first payment and whereby the sum of the pre-determined co-payment and the amount charged to the subscriber'"'"'s account is the discounted prescription price paid by the subscriber.

2. The method of claim 1 wherein the claims processor further:

a) performs a drug regimen review prior to approval of a claim; and

b) advises the pharmacy of the review results.

3. The method of claim 1, further comprising the steps of:

a) imprinting subscriber information onto identification cards; and

b) distributing the identification cards to the subscribers.

4. The method of claim 1 wherein the amount of the co-payment is determined by the medication'"'"'s inclusion, exclusion or ranking in the formulary.

5. The method of claim 1, wherein the adjudication of claims by the claims processor further comprises the steps of:

a) checking the prescription against the formulary; and

b) recommending medications to the pharmacy for fulfilling the prescription, the recommendation being determined by formulary preferences.

6. The method of claim 1 wherein the prescription benefits manager further generates reports relating to subscriber prescription claims.

7. The method of claim 1 wherein the prescription benefits manager further:

a) identifies at least one market for at least one selected prescription medication, for at least one pharmaceutical company;

b) accumulates usage data regarding consumption of the at least one selected prescription medication by the subscribers;

c) periodically provides the usage data to the pharmaceutical company; and

d) receives an incentive from the pharmaceutical company as a result of an increase in market share for the selected prescription medication among the subscribers.

8. The method of claim 7, further comprising the step of sharing at least a portion of the incentive with subscribers who contribute to the increase in market share.

9. The method of claim 8 wherein the amount of the incentive shared with a subscriber is related to that subscriber'"'"'s contribution to the increase in market share.

10. The method of claim 1 wherein an electronic means for telecommunication is used to link at least two of the participants comprising the subscriber, the prescription benefits plan sponsor, the pharmacy, the prescription benefits manager, the claims processor and the creditor or institution.

11. The method of claim 7 wherein the electronic communications network is used to link the pharmaceutical company and the prescription benefits manager.

12. The method of claim 1 wherein the first payment is in the form of a credit to an account which is periodically paid out to the prescription benefits manager.

13. The method of claim 1 wherein the sponsor reimburses the subscriber in an amount related to the subscriber'"'"'s participation in formulary-determined preferences.