Prescription drug prior authorization system and method

• US 8,265,959 B2
• Filed: 08/08/2008
• Issued: 09/11/2012
• Est. Priority Date: 01/31/2008
• Status: Active Grant

• Current Assignee: Humana Incorporated
• Original Assignee: Humana Incorporated
• Inventors: McKenzie, Ronald Keith, Stephens, Sarah, Broaddus, Kathryn Knapp, Ennis, Brad, Augspurger, Kristen R.
• Primary Examiner(s): Najarian, Lena
• Application Number:
  US12/188,431
• Publication Number:
  US 20090198518A1
• Time in Patent Office: 1,495 Days
• Field of Search: 705 2- 4
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/00 ICT specially adapted for the handling or processing of patient-related medical or healthcare data for medical reports G16H15/00; for therapies or health-improving plans G16H20/00; for the handling or processing of medical images G16H30/00
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients

Abstract

An online application for approving prior authorization requests for prescription drugs. The application is used by pharmacy benefits providers, physicians, and pharmacies to request prior authorizations for drugs and to receive approvals automatically if a requested drug meets authorization criteria. The online application is accessible through a group pharmacy benefits provider portal on a web site. Requests are processed through a pharmacy benefits manager computer that determines whether prior authorization is required and through a pharmacy benefits provider computer when the pharmacy benefits manager computer determines that prior authorization is required. Requests that meet certain authorization criteria are approved automatically. Requests that cannot be approved automatically are submitted for review by a clinical pharmacy review division that access requests through a drug request transaction computer.

Claims

1. A computerized method for processing prior authorization drug requests comprising:

(a) receiving at a rules database server an electronic prior authorization drug request, said request comprising;

(1) identifying information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member; and

(2) identifying information for a prescribing physician submitting said electronic prior authorization drug request for said member;

(b) assigning a reference identifier to said prior authorization drug request;

(c) logging said electronic prior authorization drug request with said reference identifier in a drug request transaction computer system;

(d) applying at said transaction computer system authorization criteria to said electronic prior authorization drug request to reach a prior authorization decision approving or denying dispensing of said drug to said member according to said pharmacy benefits plan for said member and said identifying information for said member;

(e) updating said electronic prior authorization drug request in said drug request transaction computer system according to said prior authorization decision;

(f) if said prior authorization drug request is automatically approved, forwarding said electronic prior authorization drug request from said rules database server to a pharmacy benefits manager computer to facilitate dispensing of said drug to said member; and

(g) if said prior authorization drug request is automatically denied, providing a computer user with access to said prior authorization request in said drug request transaction computer system.

2. The method of claim 1 wherein said identifying information for said drug prescribed to said member comprises a drug identifier, a quantity, a quantity per days value, and a number of refills.

3. The method of claim 1 wherein applying authorization criteria to said drug request comprises application of said authorization criteria by a software application at said rules database server.

4. The method of claim 1 wherein providing a computer user with access to said prior authorization request comprises providing a clinical pharmacy review representative with access to said request in said drug request transaction computer system to permit said representative to complete a prior authorization review.

5. The method of claim 4 further comprising updating said electronic prior authorization drug request logged in said drug request transaction computer system with a prior authorization approval if said representative determines said request meets said authorization criteria.

6. The method of claim 1 wherein said prior authorization drug request is for a drug selected from the group consisting of proton pump inhibitors and heartburn drugs, cox-2 inhibitor drugs, non-steroid antiinflammatory drugs, type-2 diabetes drugs, and nail fungus treatment drugs.

7. The method of claim 1 wherein said prior authorization decision is selected from the group consisting of approved, not approved, and approval not required.

8. A computerized method for processing prior authorization drug requests comprising:

(a) receiving from a pharmacy benefits manager at a rules database server an electronic prior authorization drug request to complete a prior authorization process for a prescription drug that requires prior authorization, said request comprising;

(1) identifying information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member; and

(2) identifying information for a prescribing physician submitting said electronic prior authorization drug request for said member;

(b) at said rules database server, applying a prior authorization process comprising;

(i) assigning a reference identifier to said electronic request;

(ii) adding said electronic request with said reference identifier to a drug request transaction computer system;

(iii) applying authorization criteria to said electronic request to reach a prior authorization decision approving or denying dispensing of said drug to said member according to said pharmacy benefits plan for said member and said identifying information for said member;

(iv) if said electronic request meets said authorization criteria, forwarding an electronic prior authorization approval to said pharmacy benefits manager computer; and

(v) if said electronic request does not meet said authorization criteria, providing a computer user with access to said prior authorization request in said drug request transaction computer system.

9. The method of claim 8 wherein said drug identifying information comprises a drug identifier, a quantity, a quantity per days value, and a number of refills.

10. The method of claim 8 wherein providing a computer user with access to said prior authorization request comprises providing a clinical pharmacy review representative with access to said request to permit said representative to determine if said request meets said authorization criteria.

11. The method of claim 10 further comprising permitting said clinical pharmacy review representative to access said electronic request in said drug request transaction computer system using said reference identifier.

12. The method of claim 11 further comprising updating said electronic request logged in said drug request transaction computer system with a prior authorization approval if said representative determines said request meets said authorization criteria.

13. The method of claim 8 wherein said electronic request is for a drug selected from the group consisting of proton pump inhibitors and heartburn drugs, cox-2 inhibitor drugs, non-steroid antiinflammatory drugs, type-2 diabetes drugs, and nail fungus treatment drugs.

14. The method of claim 8 wherein receiving an electronic request for a prescription drug to be dispensed to a member comprises receiving said electronic request from a device selected from the group consisting of a physician office computer, a physician office handheld device, and a pharmacy point-of-sale computer.

15. The method of claim 8 wherein said electronic request further comprises a prescription claim history for said member.

16. The method of claim 11 wherein said electronic request logged in said drug request transaction computer system further comprises a medical claim history for said member.

17. The method of claim 11 further comprising updating said electronic request in said drug request transaction computer system with a denial decision if said clinical pharmacy representative determines said request does not meet said authorization criteria.