Pharmaceutical Benefit Plan Cost Analysis Engine
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Solution Overview
Problem
Pharmaceutical benefit plan members lack the necessary information to make informed decisions about their medications, leading to increased costs and inappropriate medication usage due to the complexity and variability of benefit plans.
Innovation Solution
A method and system that analyzes prescribed medications, recommends substitute medications based on the member's pharmacy benefit plan, and facilitates approval from healthcare professionals to reduce purchasing costs, utilizing a medication analysis engine and client profile databases to provide cost-effective alternatives.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If pharmaceutical benefit plans provide coverage for a wide variety of medications including patented drugs, then members have access to appropriate treatments for their conditions, but members incur increased costs and the plan complexity increases
Solution Approach 1:
The patent introduces a pharmacy benefit manager (PBM) as an intermediary between insurers, pharmacies, and patients. The PBM manages the pharmaceutical benefit plan, processes claims, and coordinates medication coverage, thereby simplifying the complex interactions between multiple stakeholders and reducing overall system complexity while maintaining comprehensive medication access
Solution Approach 2:
The patent replaces manual medication selection and claims processing with automated computerized systems. The system automatically determines coverage, calculates costs, processes claims electronically, and provides decision support, thereby reducing the complexity of managing comprehensive pharmaceutical benefits without sacrificing treatment options
2Reliability
If pharmaceutical benefit plans cover expensive patented medications, then members receive effective treatments, but members and insurers incur increased costs
Solution Approach 1:
The patent implements feedback mechanisms where the system continuously monitors medication usage, outcomes, and costs. Clinical outcome data and cost information feed back into the system to adjust formulary decisions, prioritize high-value medications, and identify opportunities for cost-effective alternatives, thereby maintaining treatment effectiveness while controlling costs
Solution Approach 2:
The patent changes key parameters of pharmaceutical benefit plans including cost-sharing structures (copayments, deductibles), formulary tiering, and coverage criteria. By adjusting these parameters, the system balances treatment effectiveness with cost control, enabling access to necessary patented medications while managing overall expenditure through structured cost-sharing and prioritization
3Loss of energy
If pharmaceutical benefit plans have detailed coverage criteria and limitations, then insurers control costs, but members cannot make informed decisions about their medications
Solution Approach 1:
The patent introduces a decision support system and patient counseling services as intermediaries that translate complex plan details into understandable information for members. This intermediary layer explains coverage criteria, cost implications, and medication options in accessible terms, enabling informed decision-making without compromising cost control mechanisms
Solution Approach 2:
The patent segments complex pharmaceutical benefit information into manageable components such as formulary tiers, coverage categories, and cost-sharing levels. This segmentation allows the system to maintain detailed cost control criteria while presenting simplified, organized information to members through patient education materials, online portals, and counseling services
4Loss of energy
If pharmaceutical benefit plans limit coverage to reduce costs, then insurers save money, but members lose control over appropriate medication selection
Solution Approach 1:
The patent implements dynamic pharmaceutical benefit plans where coverage criteria, formulary inclusion, and cost-sharing structures can be adjusted in real-time based on clinical outcomes, cost-effectiveness data, and member needs. This dynamic approach allows the system to maintain cost control while providing members with flexible access to appropriate medications through automated re-evaluation and adjustment of coverage parameters
Data Source
AI summary
A method is described for reducing medication purchasing costs for a member of a pharmaceutical benefits plan. A member's currently prescribed medications are analyzed, and at least one substitute medication is recommended for the analyzed medication, this recommendation is based the member's pharmaceutical benefit plan. In response to the recommendation, the system receives at least one of an authorization and selection of a substitute medication. Approval for this medication is requested from the member's doctor. Further, the requested approval is sent along with a plurality of other medication substitution requests. The responses are processed to complete the substitution of the medication for the member. The member is informed that the substitute medication was approved for their purchase.