Systems and methods for administration of prescription drug benefits

• US 8,635,089 B1
• Filed: 01/14/2011
• Issued: 01/21/2014
• 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: Mahoney, Richard A., Wagner, Thomas R.
• Primary Examiner(s): Le, Michelle L
• Application Number:
  US13/007,067
• Time in Patent Office: 1,103 Days
• Field of Search: 705 2- 4, 604/131
• 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 method of administering prescription drug benefits by a computer system that comprises at least one processor, at least one interface that is operatively coupled to at least one of the processors, and at least one memory that is operatively coupled to at least one of the processors, the method comprising:

receiving via the at least one interface first medical information comprising a first medical record of a patient, the first medical record comprising a first lab result value for an analyte;

receiving via the at least one interface formulary information that is associated with the patient and comprises a lab value-dependent rule and a first formulary, the first formulary comprising information about payment by a payer for one or more drugs and the lab value-dependent rule depending on a lab result value for the analyte;

receiving via the at least one interface a request for formulary information, associated with the patient, about a drug that is specified in the request;

in response to receiving the request, generating first responsive formulary information that comprises first information about payment by the payer for the drug specified in the request, by executing instructions stored in the memory to apply the lab value-dependent rule to the first lab result value and the first formulary; and

transmitting the first responsive formulary information via the at least one interface.

2. The method of claim 1, comprising:

subsequent to transmitting the first responsive formulary information, receiving via the at least one interface second medical information comprising a second medical record of the patient, the second medical record comprising a second lab result value for the analyte that is not the first lab result value;

in response to receiving the request, generating second responsive formulary information that comprises second information about payment by the payer for the drug specified in the request, by executing instructions stored in the memory to apply the lab value-dependent rule to the second lab result value; and

transmitting the second responsive formulary information via the at least one interface.

3. The method of claim 2, wherein:

the lab value-dependent rule refers to a range of lab result values; and

applying the lab value-dependent rule to a lab result value comprises determining whether the lab result value falls in the range.

4. The method of claim 2 or claim 3, wherein the second information about payment differs from the first information about payment.

5. The method of claim 4, wherein:

the first information about payment for the specified drug indicates that the specified drug is not on the patient'"'"'s formulary; and

the first responsive formulary information comprises identification of at least one reason for exclusion of the specified drug from the patient'"'"'s formulary.

6. The method of claim 5, wherein the second information about payment indicates that the specified drug is on the patient'"'"'s formulary.

7. A computer system for administering prescription drug benefits, the computer system comprising:

at least one processor;

at least one interface that is operatively coupled to at least one of the processors; and

at least one memory that is operatively coupled to at least one of the processors 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 first medical information comprising a first medical record of a patient, the first medical record comprising a first lab result value for an analyte;

receive via the at least one interface formulary information that is associated with the patient and comprises a lab value-dependent rule and a first formulary, the first formulary comprising information about payment by a payer for one or more drugs and the lab value-dependent rule depending on a lab result value for the analyte;

receive via the at least one interface a request for formulary information, associated with the patient, about a drug that is specified in the request;

in response to receiving the request, generate first responsive formulary information that comprises first information about payment by the payer for the drug specified in the request, by applying the lab value-dependent rule to the first lab result value and the first formulary; and

transmit the first responsive formulary information via the at least one interface.

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

subsequent to transmitting the first responsive formulary information, receive via the at least one interface second medical information comprising a second medical record of the patient, the second medical record comprising a second lab result value for the analyte that is not the first lab result value;

in response to receiving the request, generate second responsive formulary information that comprises second information about payment by the payer for the drug specified in the request, by applying the lab value-dependent rule to the second lab result value; and

transmit the second responsive formulary information via the at least one interface.

9. The computer system of claim 8, wherein:

the lab value-dependent rule refers to a range of lab result values; and

applying the lab value-dependent rule to a lab result value comprises determining whether the lab result value falls in the range.

10. The computer system of claim 8 or claim 9, wherein the second information about payment differs from the first information about payment.

11. The computer system of claim 10, wherein:

the first information about payment for the specified drug indicates that the specified drug is not on the patient'"'"'s formulary; and

the first responsive formulary information comprises identification of at least one reason for exclusion of the specified drug from the patient'"'"'s formulary.

12. The computer system of claim 11, wherein the second information about payment indicates that the specified drug is on the patient'"'"'s formulary.

13. A non-transitory computer-readable storage 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 carryout a method of administering prescription drug benefits, the method comprising:

receiving via the at least one interface first medical information comprising a first medical record of a patient, the first medical record comprising a first lab result value for an analyte;

receiving via the at least one interface formulary information that is associated with the patient and comprises a lab value-dependent rule and a first formulary, the first formulary comprising information about payment by a payer for one or more drugs and the lab value-dependent rule depending on a lab result value for the analyte;

receiving via the at least one interface a request for formulary information, associated with the patient, about a drug that is specified in the request;

in response to receiving the request, generating first responsive formulary information that comprises first information about payment by the payer for the drug specified in the request, by executing instructions stored in the memory to apply the lab value-dependent rule to the first lab result value and the first formulary; and

transmitting the first responsive formulary information via the at least one interface.

14. The computer-readable storage medium of claim 13, wherein the instructions comprise instructions that, when executed by at least one of the processors, cause the computer system at least to:

subsequent to transmitting the first responsive formulary information, receiving via the at least one interface second medical information comprising a second medical record of the patient, the second medical record comprising a second lab result value for the analyte that is not the first lab result value;

in response to receiving the request, generating second responsive formulary information that comprises second information about payment by the payer for the drug specified in the request, by executing instructions stored in the memory to apply the lab value-dependent rule to the second lab result value; and

transmitting the second responsive formulary information via the at least one interface.

15. The computer-readable storage medium of claim 14, wherein:

the lab value-dependent rule refers to a range of lab result values; and

applying the lab value-dependent rule to a lab result comprises determining whether the lab result value falls in the range.

16. The computer-readable storage medium of claim 14 or claim 15, wherein the second information about payment differs from the first information about payment.

17. The computer-readable storage medium of claim 16, wherein:

the first information about payment for the specified drug indicates that the specified drug is not on the patient'"'"'s formulary; and

the first responsive formulary information comprises identification of at least one reason for exclusion of the specified drug from the patient'"'"'s formulary.

18. The computer-readable storage medium of claim 17, wherein the second information about payment indicates that the specified drug is on the patient'"'"'s formulary.