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

• US 8,380,540 B1
• Filed: 06/02/2010
• Issued: 02/19/2013
• 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., Feitel, Thomas E., Cavanagh, Brian W., Caride, Vicente L., Minardi, Giovanni C., Scullin, Shannon Sue, Gobinski, John E.
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): NGUYEN, TRANG T
• Application Number:
  US12/792,045
• Time in Patent Office: 993 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 comprising:

identifying, on a processor, a medication prescribed to a member of a pharmaceutical benefit plan for possible substitution, the pharmaceutical benefit plan being administered by a benefit manager;

determining, on the processor, a substitute medication for the identified medication based on the pharmaceutical benefits plan of the member;

receiving member authorization to substitute the substitute medication for the identified medication;

receiving an additional member authorization associated with a different member, the additional member authorization for medication substitution on behalf of the additional member;

grouping, on the processor, the member authorization and the additional member authorization for a prescriber;

providing, on the processor, a prescriber authorization request for medication substitution on behalf of the member and the additional member, the prescriber authorization request being based on grouping of the member authorization and the additional member authorization;

receiving, on the processor, a prescriber authorization response to the prescriber authorization request; and

respectively notifying the member and additional member regarding medication substitution based on the prescriber authorization response.

2. The method of claim 1, further comprising:

collecting medication claim history of the member; and

receiving member selection of the medication to be analyzed from a plurality of medications included in medication claim history of the member,

wherein identification of the medication is based on receipt of the selection.

3. The method of claim 1, further comprising:

facilitating the purchase and acquisition of an approved substitute medication.

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

5. The method of claim 1, further comprising:

administering a questionnaire to the member,

wherein determining the substitute medication is based on the pharmaceutical benefits plan of the member and a result of administration of the questionnaire to the member.

6. The method of claim 5, wherein the questionnaire includes a question on medication allergies.

7. The method of claim 1, wherein determining the substitute medication includes analyzing a formulary of the pharmaceutical benefits plan of the member to identify a lower cost medication that is a therapeutic equivalent to the medication prescribed to the member.

8. The method of claim 1, wherein the substitute medication a generic drug, a brand name drug, a therapeutic alternative drug, or an over the counter drug.

9. The method of claim 1, further comprising:

accessing information about the a physical condition of the member from laboratory results of the member,

wherein determining the substitute medication is based on the pharmaceutical benefits plan of the member and the physical condition of the member.

10. The method of claim 1, further comprising:

analyzing a plurality of medications associated with the member,

wherein identification of the medication is based on analysis of the plurality of medications.

11. The method of claim 1, further comprising:

determining an additional substitute medication for the identified medication based on the pharmaceutical benefits plan of the member; and

notifying the member of a plurality of substitute medications for the identified medication, the plurality of substitute medications including the substitute medication and the additional substitute medication,

wherein receipt of the member authorization is based on notification of the plurality of substitute medications.

12. The method of claim 11, further comprising:

receiving member selection of the substitute medication among the plurality of substitute medications based on dose and strength.

13. The method of claim 1, wherein the member authorization is received from the member and the additional member authorization is received from the different member.

14. The method of claim 1, wherein the identified medication and a medication associated with the additional member authorization for medication substitution are a same type of medication.

15. A non-transitory machine-readable medium storing instructions, which when executed by one or more processors, cause the one or more processors to perform the following operations:

identify a medication prescribed to a member of a pharmaceutical benefit plan for possible substitution, the pharmaceutical benefit plan being administered by a benefit manager;

determine a substitute medication for the identified medication based on the pharmaceutical benefits plan of the member;

receive member authorization to substitute the substitute medication for the identified medication;

receive an additional member authorization associated with a different member, the additional member authorization for medication substitution on behalf of the additional member;

group the member authorization and the additional member authorization for a prescriber;

provide a prescriber authorization request for medication substitution on behalf of the member and the additional member, the prescriber authorization request being based on grouping of the member authorization and the additional member authorization;

receive a prescriber authorization response to the prescriber authorization request; and

respectively notify the member and additional member regarding medication substitution based on the prescriber authorization response.