Invented by Alan T. Shutko, Mark G. Bini, Express Scripts Strategic Development Inc
The Express Scripts Strategic Development Inc invention works as followsA computerized location-based automated wireless distribution method includes receiving a request from a pharmacy that is associated with a plan for drug benefits. The claim specifies a first prescribed drug that will be administered to the member by the pharmacy. The method involves determining the current geographical location of a member, obtaining previously adjudicated claims data that indicates locations of a number of pharmacies from which the member has previously filled prescriptions and selecting a plan action based upon a determination as to whether the current location of the members meets a pharmacy-location criterion that is associated with at least one pharmacy in the plurality that is not selected. The method also includes automatically sending a drug benefit notice to a mobile device of the member through at least one wireless networking.
Background for Location-based automatic wireless distribution
As part of the design of a plan that includes prescription drug coverage, “Pharmacy Benefit Managers (PBMs), offer different provider networks or pharmacy network. These networks are the pharmacies or providers where a member can fill a prescription. These locations can be retail, mail-order, or a combination of both. The amount a member can pay for a drug at retail may be determined by the pharmacy provider network that is associated with the retailer location, or the reimbursement rate paid to the retail site by the PBM.
Examples of methods and systems to promote mobile awareness are described. For the purpose of explaining, many specific details will be provided in order to give a complete understanding of example embodiments. “It will be obvious to one with ordinary skill that embodiments of this invention can be practiced without the specific details.
Generally, clients engage a pharmacy benefits manager (PBM), to provide a drug benefit to their members. Clients include government organizations (e.g. Federal government agencies and Departments of Defense and Medicare and Medicaid Services, state government agencies), large employers, middle-market companies, national health insurance companies and others. PBMs can be standalone PBMs or part of larger organizations that offer other services or benefits. The methods and system can be used in general to direct a client who is a part of a drug benefit program to pharmacies that are associated with a network or association of pharmacy networks. The terms pharmacy networks and pharmacies network associations are used interchangeably here.
In some embodiments, a member can be informed of a more efficient way to use the drug benefit programs through a mobile device. The member could be informed, for example, that a certain pharmacy is not part of a pharmacy network. However, a pharmacy nearby is. A notification sent via mobile device may use the location of mobile electronic devices and the member to determine the appropriate notification. The member can receive timely and/or tailored notifications that are beneficial to them without being intrusive. The notifications could include the location of a pharmacist that is participating, the fact that the member needs to ask about a prescription refill, the need to visit the pharmacy to get a refill or the location of the pharmacy on a route. Other notifications can include information about client-savings opportunities, member savings opportunities, discounts coupons, convenience or targeted messaging.
FIG. Block diagram 1 shows an example system 100 according to an embodiment. The system 100 provides an example of a notification environment where a member or a device user assisting a member can be notified depending on their location. The system 100 consists of a mobile electronic device (102), which is in communication with a device for benefit managers (106), over a network.
The mobile electronic device 102 can be used by the device operator. The device operator can be either a participant or beneficiary in a drug plan (e.g. a spouse or child of the beneficiary). The device operator can be someone else acting on behalf the member. Parents, caregivers, and guardians are examples of these people.
The mobile electronic device 102 can be a standalone device that only provides a portion of functionality for mobile awareness or it may be an all-in-one device with functionality that is not related to mobile awareness. Mobile electronic devices powered by Android by Google, Inc., or BLACKBERRY by Research In Motion Limited are examples of mobile electronic devices 102. These devices are capable of receiving, storing, executing, and storing results from instructions. Also, other types of mobile electronics devices can be used. “These can include portable computing devices, portable communication devices, and other types of mobile electronic devices.
The network 104 through which the mobile electronic devices 102 communicate with the benefit manager device is a combination of a Mobile Communications (GSM), a Code Division Multiple Access (CDMA) Network, 3rd Generation Partnership Project (3GPP), a Wireless Application Protocol(WAP) Network, an IEEE 802.11 Standards network or an Internet Protocol (IP). Network 104 can also include optical communication. “Other conventional wired or wireless networks, including those developed later, may also be used.
The benefit manager device 106 can be operated by any entity that is at least partly responsible for the creation or management of a pharmacy benefit. The benefit manager who operates the benefit manger device 106 in most cases is a PBM. However, other entities can operate the device on behalf of the PBM or themselves.
The following may be included in the operation of the PBM which operates the benefit manager device. The member or a representative of the member attempts to obtain prescription drugs at a retail pharmacy where they can get them in person from a pharmacist, technician or in some cases via mail order.
A co-pay may be a payment that the member makes to the pharmacy for prescription drugs. The money that the member pays to the pharmacy can come from personal funds, the members health savings account (HSA), member’s families health reimbursement arrangement (HRA), flexible spending accounts (FSA), member or member’s relatives, and other sources. The member’s employer may reimburse or fund the co-pay directly or indirectly.
The benefit plan of the client may affect the amount of the member’s co-pay. The co-pay for a member may include a flat copay (e.g. $10), coinsurance (e.g. 10%) and/or a maximum $500 annual prescription drug expense (e.g. for all prescription drugs).
In certain cases, the member may pay only a part of the co-pay for prescription drugs or the entire co-pay. If the generic cost of a prescription drug is $4 and the member’s flat fee is $20, then the member can only pay $4 to get the prescription drug. A worker’s compensation claim may also be an example. In this case, the member may not have to pay a co-pay for the prescription drug.
The pharmacy will submit a claim for the prescription medication to the PBM after receiving the copay from the member (if applicable) and dispensing it to the member. The PBM can perform adjudication functions such as verifying eligibility, reviewing formulary to determine the appropriate co-pays, coinsurance and deductibles for the prescription drug and performing a Drug Utilization Review (DUR). After performing the above functions, the PBM adjudicates a claim for the prescription drug. It then provides a response back to the pharmacy. The client (or PBM acting on behalf of client) reimburses the pharmacy when adjudication of the prescription drug is successful. These adjudication functions are generally performed before the copay and prescription drug is dispensed. The operations can occur in any order, but they may also be performed simultaneously or substantially simultaneously. As part of the adjudication procedure, adjudication functions can be performed in greater or lesser numbers.
The amount of reimbursement that the client or member pays to the pharmacy may depend at least partially on the type pharmacy network within which the pharmacy is located. In addition to the pharmacy network, other factors can be used to determine reimbursement amounts.
The mobile electronic devices 102 may, on their own or in conjunction with the benefit manager device, generate a notice or promote mobile awareness based at least partly on the location (e.g. when the device operator acts on behalf or the member’s behalf) of the device operator and/or the device operator. The device operator may receive the notification through the display of the mobile device 102 or audibly through the mobile device 102. It can also be sent to another device via transmission from the mobile device 102. The notification can be communicated to the device operator or non-device operating members through multiple channels.
In some embodiments, an app or mobile application may be downloaded, launched, and installed on the mobile electronic devices 102 in order to promote mobile awareness. The mobile application can take advantage of hardware or software functionality provided by the manufacturers of mobile electronic devices 102, and/or the developers of their operating systems. The mobile application can, for example, use the SAFARI browser on the WINDOWS MOBILE or!PHONE devices, the webkit on an ANDROID, the MOBILE INTERNET explorer on a WINDOWS SMARTPHONE, or mapping on any of these devices. The mobile application can include instructions which, when executed in the benefit manager device or on the mobile electronic devices 102 and 106, cause a machine’s state to be changed or tasks to be performed within the machine or with other machines. The tasks can take information and transform it into a different output.
The mobile application can be downloaded directly from a device of the benefit manager 106 or from an application provider device. The application provider device is a device that allows mobile applications to be downloaded and used on mobile electronic devices. Apple, Inc., through the operation of ITUNES STORE, Google, Inc., through the operation of ANDROID MARKET, AT&T, through its APPCENTER, or Research In Motion Limited, through BLACKBERRY APP WORLD, are examples of companies who operate application provider device 108. These application provider devices can provide proprietary apps, open applications, and third-party apps. The application provider device 108 or the benefit manager device can provide updated versions of mobile applications, and/or the data that will be used by mobile applications.
The mobile electronic device may be in client-server relationships with the device of the application service provider 108 and/or device of the benefit management device 106, in peer-to-peer relationships with both devices, or in another type relationship.
The database 110 may store member data 112, client data 114, pharmacy data 116, prescriber information 118, and/or messaging. The database 110 can store member data 112, customer data 114 and prescriber data.
The member data 112 contains information about the members who are associated with the benefits manager. The member data 112 can include information such as name, address and telephone number. It could also include prescription drug history. The member data 112 can include a client identification number that identifies a client associated with the individual member, and/or a membership identifier which identifies a particular member to a specific client.Click here to view the patent on Google Patents.