Preferred Pharmacy Designation System for Benefit Negotiation
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Solution Overview
Problem
Pharmacy benefit managers face challenges in facilitating member preferred pharmacy designation, leading to inconsistent benefits and reimbursement rates, as existing systems lack efficient mechanisms for members to select preferred pharmacies and associate specific benefits with these choices.
Innovation Solution
A system and method that allow members to designate a preferred pharmacy through a patient device, which communicates with a benefit manager device to associate benefits and negotiate lower reimbursement rates, enabling personalized benefits and volume-based pricing discounts.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If members are allowed to designate preferred pharmacies, then member satisfaction and adherence improve, but system complexity increases due to need for tracking designations and managing different benefit levels
Solution Approach 1:
The patent segments pharmacies into different categories (preferred vs. non-preferred) and applies different benefit levels to each segment. This allows the system to manage complexity by processing pharmacies in discrete groups rather than uniformly, improving member adherence for designated pharmacies while maintaining manageable system operations through structured categorization.
Solution Approach 2:
The system dynamically adjusts benefit levels and reimbursement rates based on whether a pharmacy is designated as preferred by the member. This dynamic approach allows the system to respond to member preferences in real-time, improving adherence without requiring permanent structural changes to the entire pharmacy network, thus managing complexity through adaptability rather than rigid predetermined structures.
2Adaptability or versatility
If preferred pharmacy designation is implemented, then personalized benefits and lower costs are achieved, but loss of information increases due to need to track and manage member-pharmacy preferences
Solution Approach 1:
The patent extracts the preference tracking function from the general claim processing system, creating a dedicated mechanism for capturing and storing member-pharmacy designations. This extraction reduces the information burden on the main system by isolating preference management in a separate, specialized module that handles only the necessary data for preferred pharmacy identification, thereby enabling personalized benefits without overwhelming the entire system with tracking requirements.
Solution Approach 2:
The system introduces an intermediary data structure or module that mediates between member preferences and pharmacy claims processing. This intermediary layer captures member designations and translates them into actionable instructions for claim adjudication, reducing the direct information tracking burden on the core system while still enabling personalized benefits through the mediation of preference data.
3Loss of energy
If PBMs negotiate lower reimbursement rates with preferred pharmacies, then cost savings are achieved, but device complexity increases due to need for negotiation management and rate tracking
Solution Approach 1:
The patent applies preliminary action by establishing preferred pharmacy designations and negotiating reimbursement rates before actual claims are processed. By pre-identifying preferred pharmacies and pre-negotiating their reimbursement terms, the system avoids the complexity of negotiating rates at the point of claim processing. This advance preparation reduces the operational complexity of rate management while achieving cost savings through preferential rates for designated pharmacies.
Data Source
AI summary
Methods and systems for managing pricing guarantees for prescription drugs are described. In one embodiment, a designation of a pharmacy within a pharmacy network may be received as a preferred pharmacy designation. The preferred pharmacy designation may be associated with a member. A set of preferred pharmacy benefits may be associated with the member and the preferred pharmacy designation. A pharmacy claim associated with the preferred pharmacy designation for a prescription for the member may be adjudicated based on the set of preferred pharmacy benefits. Other methods and systems are described.