SYSTEMS AND METHODS FOR GENERATING AND MANAGING A HYBRID FORMULARY

1 . A computer-implemented method of managing a hybrid formulary for claims adjudication, the method comprising, by at least one hardware processor:

receiving a plurality of source formulary components, wherein each of the plurality of source formulary components comprises at least one of one or more drug entries, one or more tiers, and one or more utilization management rules;

receiving a configuration comprising a plurality of component identifiers and one or more hierarchy rules, wherein each of the plurality of component identifiers identifies one of the plurality of source formulary components; and

applying the one or more hierarchy rules to the identified source formulary components to generate a hybrid formulary, wherein the hybrid formulary comprises at least one of a plurality of drug entries, one or more tiers, and one or more utilization management rules.

2 . The method of claim 1 , further comprising:

receiving a request for a claim adjudication associated with a drug;

determining a response to the request based on the hybrid formulary; and

sending the response to a recipient, wherein the response comprises either a denial or an approval.

3 . The method of claim 1 , wherein one or more conflicts exist between one or more of the one or more drug entries, one or more tiers, and one or more utilization management rules of two or more of the plurality of source formulary components, and wherein applying the one or more hierarchy rules comprises utilizing the one or more hierarchy rules to resolve the one or more conflicts to generate the hybrid formulary.

4 . The method of claim 1 , further comprising periodically applying the one or more hierarchy rules to the identified source formulary components to update the hybrid formulary.

5 . The method of claim 1 , further comprising:

detecting a change in one or more of the identified source formulary components; and,

in response to the detected change, applying the one or more hierarchy rules to at least the changed one or more of the identified source formulary components to update the hybrid formulary.

6 . The method of claim 5 , wherein the detected change comprises a change in one or more of the one or more drug entries, one or more tiers, and one or more utilization management rules of at least one of the identified source formulary components.

7 . The method of claim 5 , wherein the detected change comprises an addition, a change, or a removal of a component identifier to or from the plurality of component identifiers.

8 . The method of claim 1 , wherein the one or more hierarchy rules define one or more resolutions to one or more potential conflicts between the identified source formulary components.

9 . The method of claim 8 , wherein the one or more potential conflicts comprise one or more of overlapping drug entries, overlapping tiers, and overlapping utilization management rules.

10 . The method of claim 1 , further comprising:

receiving a second configuration comprising a second plurality of component identifiers and one or more second hierarchy rules, wherein each of the second plurality of component identifiers identifies one of the plurality of source formulary components; and

applying the one or more second hierarchy rules to the identified source formulary components in the second configuration to generate a second hybrid formulary, wherein the second hybrid formulary comprises at least one of a plurality of drug entries, one or more tiers, and one or more utilization management rules.

11 . A system for managing a hybrid formulary for claims adjudication, the system comprising:

at least one hardware processor; and

at least one executable software module that, when executed by the at least one hardware processor,

receives a plurality of source formulary components, wherein each of the plurality of source formulary components comprises at least one of one or more drug entries, one or more tiers, and one or more utilization management rules,

receives a configuration comprising a plurality of component identifiers and one or more hierarchy rules, wherein each of the plurality of component identifiers identifies one of the plurality of source formulary components, and

applies the one or more hierarchy rules to the identified source formulary components to generate a hybrid formulary, wherein the hybrid formulary comprises at least one of a plurality of drug entries, one or more tiers, and one or more utilization management rules.

12 . The system of claim 11 , wherein the at least one executable software module further:

receives a request for a claim adjudication associated with a drug;

determines a response to the request based on the hybrid formulary; and

sends the response to a recipient, wherein the response comprises either a denial or an approval.

13 . The system of claim 12 , wherein one or more conflicts exist between one or more of the one or more drug entries, one or more tiers, and one or more utilization management rules of two or more of the plurality of source formulary components, and wherein applying the one or more hierarchy rules comprises utilizing the one or more hierarchy rules to resolve the one or more conflicts to generate the hybrid formulary.

14 . The system of claim 11 , wherein the at least one executable software module further periodically applies the one or more hierarchy rules to the identified source formulary components to update the hybrid formulary.

15 . The system of claim 11 , wherein the at least one executable software module further:

detects a change in one or more of the identified source formulary components; and,

in response to the detected change, applies the one or more hierarchy rules to at least the changed one or more of the identified source formulary components to update the hybrid formulary.

16 . The system of claim 15 , wherein the detected change comprises a change in one or more of the one or more drug entries, one or more tiers, and one or more utilization management rules of at least one of the identified source formulary components.

17 . The system of claim 15 , wherein the detected change comprises an addition, a change, or a removal of a component identifier to or from the plurality of component identifiers.

18 . The system of claim 11 , wherein the one or more hierarchy rules define one or more resolutions to one or more potential conflicts between the identified source formulary components.

19 . The system of claim 18 , wherein the one or more potential conflicts comprise one or more of overlapping drug entries, overlapping tiers, and overlapping utilization management rules.

20 . The system of claim 11 , wherein the at least one executable software module further:

receives a second configuration comprising a second plurality of component identifiers and one or more second hierarchy rules, wherein each of the second plurality of component identifiers identifies one of the plurality of source formulary components; and

applies the one or more second hierarchy rules to the identified source formulary components in the second configuration to generate a second hybrid formulary, wherein the second hybrid formulary comprises at least one of a plurality of drug entries, one or more tiers, and one or more utilization management rules.