PRESCRIPTION DRUG PRIOR AUTHORIZATION SYSTEM AND METHOD

• US 20090198518A1
• Filed: 08/08/2008
• Published: 08/06/2009
• Est. Priority Date: 01/31/2008
• Status: Active Grant

• Current Assignee: Humana Incorporated
• Original Assignee: Humana Incorporated
• Inventors: Stephens, Sarah, Ennis, Brad, Broaddus, Kathryn Knapp, McKenzie, Ronald Keith, Augspurger, Kristen R.
• Granted Patent: US 8,265,959 B2
• Time in Patent Office: Days
• 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 a prior authorization drug request, said request comprising identify information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member;

(b) logging said request in a drug request transaction computer system;

(c) applying authorization criteria to said drug request for 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; and

(d) forwarding a prior authorization decision for said drug request from said rules database server to a pharmacy benefits manager computer;

(e) wherein said drug is dispensed to said member according to said prior authorization decision received at said pharmacy benefits manager from said rules database server.

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 applying authorization criteria to said drug request comprises application of said authorization criteria by a representative of 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 request logged in said drug request transaction computer database 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.

11. The method of claim 10 further comprising logging said request a drug request in a transaction computer database to permit said clinical pharmacy review representative to access said request.

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

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

17. The method of claim 11 further comprising updating said 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.

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

(a) receiving at a pharmacy benefits manager computer a request for a prescription drug to be dispensed to a member covered by a pharmacy benefits plan, said request comprising member identification information and drug identifying information;

(b) determining whether said prescription drug requires prior authorization in advance of dispensing said prescription drug to said member by completing a drug utilization review;

(c) receiving said request at a rules database server to complete a prior authorization process if said prescription drug requires prior authorization, said prior authorization process at said rules database server comprising;

(i) applying authorization criteria to said prescription drug;

(ii) forwarding a prior authorization approval to said pharmacy benefits manager computer if said prescription drug meets said authorization criteria; and

(d) approving said prescription drug at said pharmacy benefits manager computer if said prescription drug does not require prior authorization.

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 further comprising forwarding said request for said prescription drug to a representative of a clinical pharmacy review representative if said rules database server determines said request does not meet said authorization criteria.

13. The method of claim 8 wherein said 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 at a pharmacy benefits manager computer a request for a prescription drug to be dispensed to a member comprises receiving said 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 request further comprises a prescription claim history for said member.