Method for providing consumer choice and equalizing pharmacy provider availability in prescription medication dispensing plans

Abstract

A method is disclosed whereby consumers enrolled in a prescription benefit plan can obtain prescription medication fulfillment at any participating pharmacy of their choice, regardless of whether the fulfillment is by a retail pharmacy or a mail order pharmacy, and whether the quantity of medication prescribed is for administration over a short period (acute care) or a prolonged period (maintenance). The plan of this invention operates by having the plan manager substantially equalize the financial effects of the discounts and services fees allowed to participating pharmacies such that both retail and mail order pharmacies are compensated in a manner which encourages them to accept all consumers and fill all prescriptions. Compensation is preferably adjusted periodically by the manager to retain pharmacy incentives. Consumers obtain choice of pharmacies, plan payers have pleased employees and members and pharmacies obtain income from the entire spectrum of consumers.

Description

FIELD OF THE INVENTION [0001] The present invention relates generally to the field of filling prescriptions for consumers. More particularly it relates to prescription payment benefits made available by health plans, employer groups, governmental entities and other organizations to their employees and / or members. BACKGROUND OF THE INVENTION [0002] Many employees and members (“consumers”) of health maintenance organizations, employer groups and government entities have their purchases of personal prescription medications subsidized by payments to pharmacies through prescription benefit plans (“plans”) offered by those health maintenance organizations, employer groups and government entities. Under such plans, a consumer receives a prescription for a medication from his or her physician and submits it to a pharmacy to be filled. The pharmacy checks to see that the consumer is a member of a plan with which the pharmacy has a contract and that the medication and dosage prescribed are wi...

AI Technical Summary

Benefits of technology

[0010] The present invention provides an innovative pharmacy-based program that allows employees / plan members who take long term maintenance medications to have a choice between obtaining such medications from a mail order pharmacy or a local retail pharmacy outlet, by effectively balancing plan reimbursement and discount payments such that both types of pharmacies are compensated essentially equally, while taking into consideration the relative operational strengths and weaknesses of each type. The consumer thus is pleased, by having a choice of pharmacies based on his / her own perceptions of the merits of each and particularly in not being deprived of such choice because of financial biases in the plan's provisions. The payer also is pleased, since the plan members are content and the plan costs are economically reasonable. The pharmacy industry as a whole also benefits, since undue biases toward mail order are avoided, retail pharmacies can effective participate in the overall dispensing of all medications and each part of the industry is able to compete on the basis of its merits of its customer service and value.

[0014] The current invention eliminates the need for multiple PCNs for the same medication for a given payer. Under the present plan each medication for a given payer has only a single PCN regardless of the quantity (number of days' supply). The pharmacist need only provide the basic data of medication identification, dosage and quantity along with the single PCN for that medication and the BIN for that payer plan. Through editing procedures internal to the PBM itself, the PBM can review the claim and based on the days supply provided by the pharmacist, correctly apply the benefit structure for the member and the appropriate reimbursement to the pharmacy. This unique editing feature enables a pharmacy to have to select and submit only a single PCN for the consumer's medication for review. This process saves time and confusion for the consumer and the pharmacy and ensures a greater utilization of the 90 day benefit which saves the payer. This applies not only to retail pharmacies, which may have a only small staff to handle such administrative matters and thus appreciate the simplification of their tasks, but also large mail order pharmacies, since elimination of the need to select among multiple PCNs for many prescriptions may allow staff to be reduced or some staff members to be reassigned to other tasks.

Problems solved by technology

Maintenance medication dispensing and usage represents a major health care cost (on the order of 75% of prescription costs for many plans, especially due to the aging of the American population) and therefore control of maintenance prescription costs is a principal function of the prescription benefit plans.

It is normally recognized by the industry that acute care prescriptions are dispensed primarily by retail pharmacies, since the consumer frequently needs the medication immediately and cannot accept the multi-day delay inherent in submitting and dispensing prescription medications from the mail order pharmacies.

However, several factors can complicate the analysis of use of mail order pharmacies versus use of retail pharmacies especially for dispensing of maintenance medications.

Further, to the extent that business is diverted unreasonably from retail pharmacies to mail order pharmacies, the former are deprived of income.

Since the retail pharmacies are commonly localized businesses (in contrast to mail order pharmacies), their ability to survive to provide the local retail service is impaired.

This is true even when a local pharmacy is part of a larger chain pharmacy organization, since decline in income of a local site could lead the chain to close that local site, notwithstanding that other locations of the chain's pharmacies remain in business.

Further, there are many variables in the pricing of medications and the costs involved in inventories, dispensing equipment, transportation of medications to the pharmacy and later to the consumer and staffing, that have been shown to affect whether mail order does or does not have a financial advantage over retail in the dispensing of medications.

Most consumers are not knowledgeable about medications and a prescribing physician's schedule may not provide sufficient time for a consumer to be able to get what he or she believes to be sufficient information from the prescribing physician about all aspects of concern about a prescribed medication.

Such direct and personal contact with a pharmacist is frequently difficult for a consumer to obtain from a mail order pharmacy, and even when available will almost certainly not involve a pharmacist who is “local” to the consumer and his / her community.

This leads to consumer and payer dissatisfaction.

When a lower of MAC or AWP model is used a payer can not guarantee an overall generic performance.

When a lower of MAC or AWP model is used the pharmacy can not be sure of its reimbursement.

Since the consumer only presents one identification card, this process can cause confusion at the pharmacy.

It can cause confusion and delays at the point of sale transaction that impact both the consumer and the pharmacy.

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