Pharmacy Benefits Management System Cost Transparency
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Solution Overview
Problem
Current pharmacy benefit management systems fail to effectively reduce prescription drug costs due to lack of transparency in cost information for patients and providers, with Pharmacy Benefit Managers (PBMs) often prioritizing rebate-driven profit margins over cost-effective options, leading to inefficient drug therapy decisions.
Innovation Solution
A pharmacy benefits management system and method that provides access to cost and clinical information through a processor server, management server, and provider server, correlating claim information with benefits plan structure and formulary data to identify dispensed drugs, associated expenses, and alternative cost-effective options, allowing patients and providers to make informed decisions.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Loss of energy
If PBMs use complex rebate plans and formularies to manage pharmacy benefits, then cost control mechanisms are established, but transparency of actual drug costs to patients and providers is lost
Solution Approach 1:
The patent introduces a computer-based information system as an intermediary between the PBM's complex rebate structures and the end users (patients and providers). This system translates obscured cost data into transparent, accessible information while maintaining the rebate control mechanisms, allowing both cost control and information transparency to coexist.
Solution Approach 2:
The system provides real-time feedback to patients and providers about actual drug costs, alternative options, and cost implications before prescription fulfillment. This feedback loop enables informed decision-making while preserving the PBM's cost control structures through transparent information delivery.
2Ease of operation
If PBMs process claims through independent claims processing to control costs, then administrative functions are separated, but effective cost reduction is not achieved
Solution Approach 1:
The patent empowers patients and providers to actively participate in cost-effective drug selection through direct access to cost information and alternative drug data. This self-service approach complements the independent claims processing by enabling frontline decision-makers to choose cost-effective options without requiring complex PBM intervention, thereby achieving actual cost reduction.
3Loss of energy
If formularies direct patients to lowest cost drugs on paper, then cost minimization is intended, but actual patient and provider awareness of costs remains zero
Solution Approach 1:
The system provides cost information and alternative drug data to patients and providers before the prescription fulfillment decision is made. This preliminary action ensures that cost-conscious decisions are informed by actual data rather than theoretical formulary restrictions, bridging the gap between formulary intent and real-world cost awareness.
Data Source
AI summary
A pharmacy benefits management system and method. A processor server has claim information relating to pharmacy benefits claims, and information relating to a claims processing formularly stored therein. A provider server has pharmacy benefits plan structure information stored therein. A management server has price information relating drugs in various classes and a processing module for correlating the claim information with the benefits plan structure information and the formularly information to identify drugs dispensed to patients, expenses associated with the drugs in accordance with the pharmacy benefits plan structure information, alternative drugs in the same class as the drugs and expenses associated with the alternative drugs.