Computer implemented method and system for analyzing pharmaceutical benefit plans and for providing member specific advice, optionally including lower cost pharmaceutical alternatives

• US 7,734,483 B1
• Filed: 05/21/2007
• Issued: 06/08/2010
• Est. Priority Date: 05/20/2006
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Smith, Jack A., Caride, Vicente L., Feitel, Thomas E., Scullin, Shannon Sue, Cavanagh, Brian W., Gobinski, John E., Minardi, Giovanni C.
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): NGUYEN, TRANG T
• Application Number:
  US11/804,890
• Time in Patent Office: 1,114 Days
• Field of Search: 705/2, 705/3
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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

A method is described for reducing medication purchasing costs for a member of a pharmaceutical benefits plan. A member'"'"'s currently prescribed medications are analyzed, and at least one substitute medication is recommended for the analyzed medication, this recommendation is based the member'"'"'s pharmaceutical benefit plan. In response to the recommendation, the system receives at least one of an authorization and selection of a substitute medication. Approval for this medication is requested from the member'"'"'s doctor. Further, the requested approval is sent along with a plurality of other medication substitution requests. The responses are processed to complete the substitution of the medication for the member. The member is informed that the substitute medication was approved for their purchase.

Claims

1. A method implemented by a pharmaceutical benefits management computer system used by a pharmaceutical benefits manager, for reducing medication purchasing costs for a member of a pharmaceutical benefits plan managed by the pharmaceutical benefits manager, comprising the steps of:

(a) analyzing using the pharmaceutical benefits management computer system, a medication prescribed to the member;

(b) recommending at least one substitute medication for the analyzed medication, wherein the recommendation is based on the pharmaceutical benefits plan of the member, and wherein the member'"'"'s pharmaceutical benefits plan of the member is managed by the pharmaceutical benefits management computer system;

(c) receiving, from the member, at least one of an authorization and selection of a substitute medication from the at least one recommended medication;

(d) requesting approval from at least one of an authorizing physician, a pharmacist and an authorizing health care professional for the selected substitute medication;

(e) grouping the requested approval with a plurality of other requests received for approvals of substitute medication for a plurality of members associated with same said at least one of the authorizing physician, the pharmacist and the authorizing health care professional, wherein the other requests for approval are received from a plurality of members of pharmaceutical benefit plans managed by the pharmaceutical benefits management system, and wherein said grouping enables said same at least one of the authorizing physician, the pharmacist and the authorizing health care professional for the plurality of members, to respond to the requested approval and the other requests for at least one of the selected substitute medication and other medications;

(f) processing by the pharmaceutical benefits management computer system the response to the requested approval and the other requests for the at least one of the selected substitute medication and the other medications for the plurality of members; and

(g) informing the plurality of members corresponding to the requested group approval, whether the substitute medication was approved.

2. The method of claim 1, further comprising the step of:

collecting medication claim history of the member; and

allowing the member to select the medication to be analyzed from the set of medications in their medication claim history.

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

facilitating the purchase and acquisition of the approved substitute medication.

4. The method of claim 3, wherein facilitating the purchase and acquisition of the approved substitute medication comprises displaying a plurality of pharmacies selling the approved substitute medication.

5. The method of claim 1, further comprising the step of:

administering a questionnaire to the member before recommending the at least one substitute medication.

6. The method of claim 5, wherein the questionnaire has at least one question on medication allergies.

7. The method of claim 1, wherein recommending a least one substitute drug comprises analyzing the formulary of the member'"'"'s pharmaceutical benefits plan to find a lower cost medication that is a therapeutic equivalent.

8. The method of claim 1, wherein the possible responses from the at least one of an authorizing physician, a pharmacist, and an authorizing health care professional, to the request for approval include, approve, deny, or see member.

9. The method of claim 1, wherein the recommended substitute medication is at least one of a generic drug, brand name drug, therapeutic alternative drug, and over the counter drug.

10. The method of claim 1, wherein steps (b), (c), and (g) are done over the phone.

11. The method of claim 1, wherein steps (b), (c) and (g) are done through the mail.

12. The method of claim 1, further comprising maintaining a database of responses from the at least one of an authorizing physician, a pharmacist and an authorizing health care professional;

and using the database when recommending at least one lower cost substitute medication.

13. The method of claim 1, wherein grouping the requested approval with a plurality of other medication substitution requests is done by grouping substitution requests for the analyzed medication together.

14. The method of claim 1, wherein analyzing a medication prescribed to a member uses information about the member'"'"'s physical condition obtained from the member'"'"'s laboratory results.

15. The method of claim 1, wherein receiving, from the member, at least one of an authorization and selection of a substitute medication based on dose and strength.

16. The method of claim 1, wherein analyzing a medication prescribed to the member and recommending at least one substitute medication for the analyzed medication, is initiated by the pharmaceutical benefits manager.

17. The method of claim 16, wherein analyzing a medication prescribed to the member, and recommending at least one substitute medication for the analyzed medication, is initiated by the pharmaceutical benefits manager in response to a medication claim history of the member including a medication for a chronic condition.

18. A computer implemented system provided by a pharmaceutical benefits manager, for reducing medication purchasing costs for a member of a pharmaceutical benefits plan managed by the pharmaceutical benefits manager, comprising:

a medication analysis engine, provided by a pharmaceutical benefits manager, executing on a computer, analyzing a medication prescribed to the member;

a plurality of databases connected to the medication analysis engine, including at least a medication information database, and a client profile database comprising pharmaceutical benefits plan information for members;

recommending at least one substitute medication for the analyzed medication, wherein the recommendation is based on the client profile database and a member'"'"'s pharmaceutical benefits plan, and wherein the recommendation is based on known medication substitutions, and wherein the member'"'"'s pharmaceutical benefits plan is managed by the pharmaceutical benefits manager;

where the medication analysis engine receives from a client interface, operated by the member, an authorization and selection an of a substitute medication from the at least one recommended medication;

the medication analysis engine requesting approval from at least one of an authorizing physician, a pharmacist, and an authorizing health care professional, for the selected substitute medication;

an approval request with the requested approval, and a plurality of other medication substitution requests grouped together on the approval request wherein the plurality of other medication substitution requests are from a plurality of members of pharmaceutical benefit plans managed by the pharmaceutical benefits manager for a plurality of members associated with said at least one of the authorizing physician, the pharmacist and the authorizing health care professional, and wherein said grouping enables said same at least one of the authorizing physician, the pharmacist and the authorizing health care professional for the plurality of members, to respond to the requested approval and the other requests for at least one of the selected substitute medication and other medications;

the medication analysis engine processing the response to the requested approval and the other requests for the at least one selected substitute of the medication and the other medications for the members; and

an interface for informing the member that the substitute medication was approved.

19. The system of claim 18, further comprising

a database of medication claim history of the member, wherein the database is used to populate an interface allowing the member to select the medication to be analyzed.

20. The system of claim 18, further comprising a questionnaire from the member providing data to the medication analysis engine.

21. The system of claim 18, further comprising a database of responses, wherein the database is used when recommending at least one substitute medication.

22. The system of claim 18, further comprising a database of international classification of disease codes, the international classification of disease codes being used to recommend at least one substitute medication.

23. The system of claim 18, further comprising a database for storing both recommended and non-recommended substitute medications for a plurality of members whose medications have been analyzed.

24. The system of claim 18, further comprising a reporting engine for providing to the interface one or more substitute medications formatted appropriately for the interface.

25. The system of claim 18, further comprising a patient stratification component connected to the medication analysis engine, wherein the patient stratification component provides information used in recommending at least one substitute medication.

26. The system of claim 18, further comprising:

a database of medication claim history of the member, wherein the database is used to populate an interface allowing the member to select the medication to be analyzed;

a database of responses, wherein the database is used when recommending at least one substitute medication;

a database of international classification of disease codes, the international classification of disease codes being used by the medication analysis engine to recommend at least one substitute medication;

a database for storing both recommended and non-recommended substitute medications for a plurality of members whose medications have been analyzed; and

a reporting engine for providing to the interface one or more substitute medications formatted appropriately for the interface.

27. The system of claim 18, further comprising a database of the member'"'"'s laboratory results, wherein the results are used by the medication analysis engine to recommend a substitute drug.

28. The system of claim 18, wherein analyzing a medication prescribed to the member and recommending at least one substitute medication for the analyzed medication, is initiated by the medication analysis engine.

29. The system of claim 28, wherein the medication analysis engine analyzing a medication prescribed to the member and recommending at least one substitute medication for the analyzed medication, is initiated by the medication analysis engine in response to a medication claim history of the member including a medication for a chronic condition.

30. A method, implemented by a pharmaceutical benefits management computer system used by a pharmaceutical benefits manager, for reducing medication purchasing costs for a member of a pharmaceutical benefits plan managed by the pharmaceutical benefits manager, comprising:

(a) requesting a medication to be analyzed from a member;

(b) analyzing using the pharmaceutical benefits management computer system, the medication requested by the member;

(c) recommending at least one substitute medication for the analyzed medication, wherein the recommendation is based on the pharmaceutical benefits plan of the member, and wherein the member'"'"'s pharmaceutical benefits plan of the member is managed by the pharmaceutical benefits management computer system, and on a database of known medication substitutes;

(d) receiving, from the member, at least one of an authorization and selection of a substitute medication for the at least one recommended medication;

(e) requesting approval from at least one of an authorizing physician, a pharmacist and an authorizing health care professional, for the selected substitute medication;

(f) grouping the requested approval with a plurality of other requests received for approvals of substitute medication for a plurality of members associated with same said at least one of the authorizing physician, the pharmacist and the authorizing health care professional, wherein the other requests for approval are received from a plurality of members of pharmaceutical benefit plans managed by the pharmaceutical benefits management system, and wherein said grouping enables said same at least one of the authorizing physician, the pharmacist and the authorizing health care professional for the plurality of members, to respond to the requested approval and the other requests for at least one of the selected substitute medication and other medications;

(g) processing by the pharmaceutical benefits management computer system the response to the requested approval and the other requests for the at least one of the selected substitute medication and the other medications for the plurality of members; and

(h) informing the plurality of members corresponding to the requested group approval, whether the substitute medication was approved.

31. The method of claim 30, further comprising the step of:

facilitating at least one of the acquisition and purchase of the approved substitute medication.

32. The method of claim 30, wherein the possible responses to the request for approval include approve, deny, or see member.

33. The method of claim 30, further comprising the step of:

maintaining a database of responses from the at least one of an authorizing physician, a pharmacist and an authorizing health care professional; and

using the database when recommending at least one substitute medication.

34. A method, implemented by a pharmaceutical benefits management computer system used by a pharmaceutical benefits manager, for reducing medication purchasing costs for a member of a pharmaceutical benefits plan managed by the pharmaceutical benefits manager, using a wireless mobile computing device comprising:

(a) requesting a medication to be analyzed from a member using a wireless mobile computing device;

(b) analyzing using the pharmaceutical benefits management computer system, the medication requested by the member;

(c) recommending at least one substitute medication for the analyzed medication, wherein the recommendation is based on the pharmaceutical benefits plan of the member, and wherein the member'"'"'s pharmaceutical benefits plan of the member is managed by the pharmaceutical benefits management computer system;

(d) receiving, from the member, at least one of an authorization and selection of a substitute medication for the at least one recommended medication;

(e) requesting approval from at least one of an authorizing physician, a pharmacist and an authorizing health care professional, for the selected substitute medication;

(f) grouping the requested approval with a plurality of other requests received for approvals of substitute medication for a plurality of members associated with same said at least one of the authorizing physician, the pharmacist and the authorizing health care professional, wherein the other requests for approval are received from a plurality of members of pharmaceutical benefit plans managed by the pharmaceutical benefits management system, and wherein said grouping enables said same at least one of the authorizing physician, the pharmacist and the authorizing health care professional for the plurality of members, to respond to the requested approval and the other requests for at least one of the selected substitute medication and other medications;

(g) processing by the pharmaceutical benefits management computer system the response to the requested approval and the other requests for the at least one of the selected substitute medication and the other medications for the plurality of members; and

(h) informing the plurality of members corresponding to the requested group approval, through the interface of the wireless mobile computing device, whether the substitute medication was approved.

35. A computer implemented system for reducing medication purchasing costs for a member of a pharmaceutical benefits plan comprising:

a medication analysis engine executing on a computer, analyzing a medication prescribed to the member, the member selecting the medication from a database of medication claim history of the member, wherein the database is used to populate an interface allowing the member to select the medication to be analyzed;

a plurality of databases connected to the medication analysis engine, including at least a client profile database comprising pharmaceutical benefits plan information for members;

recommending at least one substitute medication for the analyzed medication, wherein the recommendation is based on the client profile database and a member'"'"'s pharmaceutical benefits plan, and wherein the recommendation is based on known medication substitutions, and wherein at least one of the recommendations is stored in a database linked to the analyzed medication;

wherein the medication analysis engine receives from a client interface, operated by the member, an authorization and selection of a substitute medication for the at least one recommended medication;

the medication analysis engine requesting approval from at least one of an authorizing physician, a pharmacist, and an authorizing health care professional, for the selected substitute medication;

an approval request with the requested approval, and a plurality of other medication substitution requests grouped together on the approval request, for a plurality of members associated with same said at least one of the authorizing physician, the pharmacist and the authorizing health care professional, and wherein said grouping enables said same at least one of the authorizing physician, the pharmacist and the authorizing health care professional for the plurality of members, to respond to the requested approval and the other requests for at least one of the selected substitute medication and other medications;

the medication analysis engine processing the response to the requested approval and the other requests, the response being stored along with a plurality of other responses in a database of responses for the at least one selected substitute of the medication and the other medications for the members;

and an interface for informing the member that the substitute medication was approved for at least one of their purchase and acquisition.