Systems and methods for administration of prescription drug benefits
View Patent ↗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.
1. A method of providing dynamic formulary information in real time during electronic prescribing, comprising:
storing in a network-based non-transitory storage device formulary information that is associated with a patient and comprises at least one rule and a first formulary, the first formulary comprising information about payment by a payer for one or more drugs;
providing remote access to clients over a network so any one of the clients can request formulary information in real time in the course of creating an electronic prescription;
receiving from one of the clients over the network a request for formulary information pertaining to the patient and to one or more medications;
in response to receiving the request for formulary information, automatically retrieving medical information comprising at least one record of a patient from a first electronic information source over the network;
receiving the medical information in a standardized format from an adaptor;
in response to receiving the request for formulary information, automatically generating by a dynamic risk-adjusted formulary manager (DRAFM) server a dynamic second formulary, comprising information about payment by the payer for one or more drugs by applying the at least one rule to the standardized medical information and the first formulary;
storing the second formulary in the DRAFM server ;
automatically generating a message, by an adaptor in communication with the DRAFM server, containing information from the second formulary in response to the request for formulary information; and
transmitting the message to the client in real time, so that the client has immediate access to dynamic formulary information.
2. The method of claim 1 , wherein the message containing information from the second formulary includes first information that identifies at least one drug that is in the second formulary and second information that identifies at least one drug that is not in the second formulary.
3. The method of claim 2 , wherein the second information includes identification of at least one reason for exclusion of at least one of the drugs that is not in the second formulary.
4. The method of claim 2 , wherein the second information includes identification of at least one condition such that if the at least one condition is fulfilled, then at least one of the drugs that is not in the second formulary before fulfillment of the condition will be in the second formulary after fulfillment of the condition.
5. The method of claim 4 , wherein at least one of the conditions includes subjecting the patient to a medical test.
6. The method of claim 1 , wherein:
the request for formulary information identifies a candidate drug; and
the message containing information from the second formulary includes indication that the candidate drug is not in the second formulary and identification of at least one alternate drug that is on the second formulary and may be prescribed instead of the candidate drug.
7. The method of claim 1 , wherein the at least one rule includes at least one conditional rule that depends on the medical information.
8. The method of claim 7 , wherein at the at least one conditional rule includes at least one rule that depends on the age of the patient.
9. The method of claim 7 , wherein at the at least one conditional rule includes at least one rule that depends on the sex of the patient.
10. The method of claim 7 , wherein at the at least one conditional rule includes at least one rule that depends on one or more records of medical tests performed upon the patient.
11. The method of claim 7 , wherein at the at least one conditional rule includes at least one rule that depends on one or more records of diagnosed medical conditions associated with the patient.