Prescription drug prior authorization system and method

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.

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...

AI Technical Summary

Benefits of technology

The present invention provides a portal and application that make it easy for pharmacy benefit network providers to request preferred pharmacy assistants (PAs) for commonly prescribed drugs. This saves time and ensures that PAs are requested in accordance with the pharmacy benefits plan's criteria. The application complies with regulatory guidelines and is designed to streamline the process of prior authorization for Center for Medicare and Medicaid Services (CMS) benefits.

Problems solved by technology

Prescription drug costs are contributing significantly to increases in overall U.S. healthcare spending.

Some drugs may have limited uses based on studies or FDA approval.

Although PA provides cost-savings to pharmacy benefits providers and their covered individuals, the approach also involves an administrative overhead that reduces the potential of the costs-savings.

Such systems, however, typically allow only one party such as a pharmacist to submit a PA drug request.

Images