Prescription drug prior authorization system and method

a technology for prior authorization and prescription drugs, applied in drug and medication, data processing applications, finance, etc., can solve the problems of limited use, reduced cost-saving potential, and high cost of prescription drugs, so as to facilitate the submission of pa requests, facilitate use, and facilitate the effect of time efficient and effectiv

US20160358288A1Inactive Publication Date: 2016-12-08HUMANA INC
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Patent Information

Authority / Receiving Office
US · United States
Patent Type
Applications(United States)
Current Assignee / Owner
Publication Date
2016-12-08
Estimated Expiration
Not applicable · inactive patent

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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.
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Description

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of U.S. patent application Ser. No. 12 / 188,431, titled PRESCRIPTION DRUG PRIOR AUTHORIZATION SYSTEM AND METHOD, filed Aug. 8, 2008, now U.S. Pat. No. 8,265,959, issued Sep. 11, 2012 and U.S. Provisional Patent Application Ser. No. 61 / 025,148, filed Jan. 31, 2008.FIELD OF THE INVENTION

[0002] The present invention relates to prescription drug prior authorization systems and methods. In particular, the present invention is computerized prior authorization system and method that provides online, real-time prescription drug prior authorizations through multiple interfaces to a single, comprehensive authorization process.BACKGROUND OF THE INVENTION

[0003] Prescription drug costs are contributing significantly to increases in overall U.S. healthcare spending. In an effort to control the escalating costs of prescription drugs, more and more pharmacy benefits providers are using Prior Authorization (“PA”). Prior au...

Examples

Embodiment Construction

[0015]Referring to FIG. 1B, a first system for providing prior authorization for prescription drugs according to an example embodiment of the present invention is shown. A physician uses a computer 118 to submit a PA drug request 120 to a rules database server 122. The drug request 120 comprises member identifying data, drug identifying data as well as dosage, form, and quantity information. The rules database server 122 may be part of a group provider computer system such as one operated by Humana. The rules database server 122 and compares the drug request to rules related to the member's plan benefits and PA criteria. The drug request is also logged in a drug request transaction computer system 124 so that information about the drug request transaction can be recorded and accessed for later retrieval (e.g., by a representative of a clinical pharmacy review division). The rules database server 122 applies the authorization criteria to the drug request 126. If the drug request meet...