Systems and methods for administration of prescription drug benefits

• US 7,895,060 B1
• Filed: 02/03/2006
• Issued: 02/22/2011
• Est. Priority Date: 02/03/2006
• Status: Active Grant

• Current Assignee: Quest Diagnostics Investments Incorporated (Quest Diagnostics Incorporated)
• Original Assignee: Quest Diagnostics Investments Incorporated (Quest Diagnostics Incorporated)
• Inventors: Wagner, Thomas R., Mahoney, Richard A.
• Primary Examiner(s): LE, LINH GIANG
• Application Number:
  US11/347,144
• Time in Patent Office: 1,845 Days
• Field of Search: 705 2- 4, 600/300
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/06 Buying, selling or leasing transactions
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 50/22 Social work or social welfare, e.g. community support activities or counselling services
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/00 ICT specially adapted for therapies or health-improving plans, e.g. for handling prescriptions, for steering therapy or for monitoring patient compliance
• 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
• CPC Class Codes: G16H 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

Abstract

The invention relates to the administration of prescription drug formulary information. A list of drugs that a particular prescription drug plan will pay for in whole or in part is called a formulary. The invention involves the use of information and customizable rules associated with formularies, combined with information from patient medical records, to generate custom, dynamic formularies applicable to specific patients, groups of patients, or both. Depending on the choice of rules and the other information, this may help payers control prescription drug costs by encouraging the use of less-expensive drugs when medically appropriate, but without impairing the freedom of prescribers to prescribe specific drugs according to their professional judgments. Some embodiments may also be adapted to generate and store data about the use and functioning of the embodiments or aspects of them and to generate reports containing some or all such data in response to queries.

Claims

1. A computer system for processing information related to formularies, comprising:

at least one processor;

at least one interface, operatively coupled to the at least one processor; and

at least one memory, operatively coupled to the at least one processor and encoded with instructions that, when executed by at least one of the processors, cause the computer system at least to

receive via the at least one interface medical information comprising at least one medical record of a patient from a first electronic information source;

receive via the at least one interface, from a second electronic information source, formulary information that is associated with the patient and comprises at least one rule and a first formulary, the first formulary comprising information about payment by a payer for one or more drugs; and

generate a second formulary, comprising information about payment by the payer for one or more drugs, by applying the at least one rule to the at least one medical record and the first formulary.

2. The computer system of claim 1, wherein the instructions comprise instructions that, when executed by at least one of the processors, cause the computer system at least to transmit information from the second formulary via the at least one interface.

3. The computer system of claim 2, wherein the transmitted information includes first information comprising identification of at least one drug that is on the second formulary and second information comprising identification of at least one drug that is not on the second formulary.

4. The computer system of claim 3, wherein the second information comprises identification of at least one reason for exclusion of at least one of the drugs that is not on the second formulary.

5. The computer system of claim 3, wherein the second information comprises identification of at least one condition such that if the at least one condition is fulfilled, then at least one of the drugs that is not on the second formulary before fulfillment of the condition will be on the second formulary after fulfillment of the condition.

6. The computer system of claim 5, wherein at least one of the conditions includes subjecting the patient to a medical test.

7. The computer system of claim 1, wherein the instructions comprise instructions that, when executed by at least one of the processors, cause the computer system at least to:

receive first prescription information via the at least one interface, the first prescription information comprising identification of a drug that has been prescribed for a patient; and

in response to receiving the first prescription information, transmit second prescription information via the at least one interface, the second prescription information comprising indication of whether the drug is on the second formulary;

wherein generating the second formulary occurs in response to receiving the first prescription information.

8. The computer system of claim 7, wherein the second prescription information comprises indication that the drug is not on the second formulary and identification of at least one alternate drug that is on the second formulary and that may be prescribed instead of the drug.

9. The computer system of claim 1, wherein the at least one rule comprises at least one conditional rule that depends on the medical information.

10. The computer system of claim 9, wherein at least one conditional rule includes at least one rule that depends on the age of the patient.

11. The computer system of claim 9, wherein at least one conditional rule includes at least one rule that depends on the sex of the patient.

12. The computer system of claim 9, wherein at least one conditional rule includes at least one rule that depends on one or more records of medical tests performed upon the patient.

13. The computer system of claim 9, wherein at least one conditional rule includes at least one rule that depends on one or more records of diagnosed medical conditions associated with the patient.

14. A method of processing, by a computer system comprising at least one processor, at least one interface that is operatively coupled to the at least one processor, and at least one memory that is operatively coupled to the at least one processor, information related to formularies, the method comprising:

receiving via the at least one interface medical information comprising at least one medical record of a patient from a first electronic information source;

receiving via the at least one interface, from a second electronic information source, formulary information that is associated with the patient and comprises at least one rule and a first formulary, the first formulary comprising information about payment by a payer for one or more drugs; and

generating a second formulary, comprising information about payment by the payer for one or more drugs, by executing instructions stored in the at least one memory to apply the at least one rule to the at least one medical record and the first formulary.

15. The method of claim 14, comprising transmitting information from the second formulary via the at least one interface.

16. The method of claim 15, wherein the transmitted information includes first information comprising identification of at least one drug that is on the second formulary and second information comprising identification of at least one drug that is not on the second formulary.

17. The method of claim 16, wherein the second information comprises identification of at least one reason for exclusion of at least one of the drugs that is not on the second formulary.

18. The method of claim 16, wherein the second information comprises identification of at least one condition such that if the at least one condition is fulfilled, then at least one of the drugs that is not on the second formulary before fulfillment of the condition will be on the second formulary after fulfillment of the condition.

19. The method of claim 18, wherein at least one of the conditions includes subjecting the patient to a medical test.

20. The method of claim 14, comprising:

receiving first prescription information via the at least one of interface, the first prescription information comprising identification of a drug that has been prescribed for a patient; and

in response to receiving the first prescription information, transmitting second prescription information via the at least one interface, the second prescription information comprising indication of whether the drug is on the second formulary;

wherein generating the second formulary occurs in response to receiving the first prescription information.

21. The method of claim 20, wherein the second prescription information comprises indication that the drug is not on the second formulary and identification of at least one alternate drug that is on the second formulary and that may be prescribed instead of the drug.

22. The method of claim 14, wherein the at least one rule comprises at least one conditional rule that depends on the medical information.

23. The method of claim 22, wherein at least one conditional rule includes at least one rule that depends on the age of the patient.

24. The method of claim 22, wherein at least one conditional rule includes at least one rule that depends on the sex of the patient.

25. The method of claim 22, wherein at least one conditional rule includes at least one rule that depends on one or more records of medical tests performed upon the patient.

26. The method of claim 22, wherein at least one conditional rule includes at least one rule that depends on one or more records of diagnosed medical conditions associated with the patient.

27. A computer-readable medium encoded with instructions such that the instructions, when executed by at least one processor within a computer system that comprises the at least one processor, at least one interface operatively coupled to the at least one processor, and at least one memory operatively coupled to the at least one processor, cause the computer system to carry out a method of processing information related to formularies, the method comprising:

receiving via the at least one interface medical information comprising at least one medical record of a patient from a first electronic information source;

receiving via the at least one interface, from a second electronic information source, formulary information that is associated with the patient and comprises at least one rule and a first formulary, the first formulary comprising information about payment by a payer for one or more drugs; and

generating a second formulary, comprising information about payment by the payer for one or more drugs, by executing instructions stored in the at least one memory to apply the at least one rule to the at least one medical record and the first formulary.

28. The computer-readable medium of claim 27, wherein the method comprises transmitting information from the second formulary via the at least one interface.

29. The computer-readable medium of claim 28, wherein the transmitted information includes first information comprising identification of at least one drug that is on the second formulary and second information comprising identification of at least one drug that is not on the second formulary.

30. The computer-readable medium of claim 29, wherein the second information comprises identification of at least one reason for exclusion of at least one of the drugs that is not on the second formulary.

31. The computer-readable medium of claim 30, wherein the second information comprises identification of at least one condition such that if the at least one condition is fulfilled, then at least one of the drugs that is not on the second formulary before fulfillment of the condition will be on the second formulary after fulfillment of the condition.

32. The computer-readable medium of claim 31, wherein at least one of the conditions includes subjecting the patient to a medical test.

33. The computer-readable medium of claim 27, wherein the method comprises:

receiving first prescription information via the at least one of interface, the first prescription information comprising identification of a drug that has been prescribed for a patient; and

in response to receiving the first prescription information, transmitting second prescription information via the at least one interface, the second prescription information comprising indication of whether the drug is on the second formulary;

wherein generating the second formulary takes place in response to receiving the first prescription information.

34. The computer-readable medium of claim 33, wherein the second prescription information comprises indication that the drug is not on the second formulary and identification of at least one alternate drug that is on the second formulary and that may be prescribed instead of the drug.

35. The computer-readable medium of claim 27, wherein the at least one rule comprises at least one conditional rule that depends on the medical information.

36. The computer-readable medium of claim 35, wherein at least one conditional rule includes at least one rule that depends on the age of the patient.

37. The computer-readable medium of claim 35, wherein at least one conditional rule includes at least one rule that depends on the sex of the patient.

38. The computer-readable medium of claim 35, wherein at least one conditional rule includes at least one rule that depends on one or more records of medical tests performed upon the patient.

39. The computer-readable medium of claim 35, wherein at least one conditional rule includes at least one rule that depends on one or more records of diagnosed medical conditions associated with the patient.