Invented by Jacob Jon Cedergreen, Katherine Harini Sundararaman, Christopher Ray Fowler, Express Scripts Strategic Development Inc
The Express Scripts Strategic Development Inc invention works as follows
Methods, systems and methods for managing price guarantees for prescription drugs are described. A preferred pharmacy designation may be defined as the designation of a pharmacy in a network. A member may have a preferred pharmacy designation. The member may have a set of preferred pharmacy benefits. The set of preferred pharmacy benefits may be used to adjudicate a pharmacy claim for a member’s prescription. These are just a few of the many methods and systems that exist.
Background for Methods, systems and methods for preferred pharmacy designation
Pharmacy benefit mangers generally offer prescription drug programs to clients. They may sponsor, for instance, drug benefit programs for members. Pharmacy benefit managers (PBM) can adjudicate prescription claims from pharmacies. PBMs may reimburse pharmacies for prescriptions that members have obtained at pharmacies. Clients may be charged by the PBM for prescriptions that are adjudged by the pharmacy benefit manger.
Examples of preferred pharmacy designation systems and methods are described. The following description provides a detailed explanation of several examples of embodiments. However, it will be obvious to those with ordinary skill in art that embodiments may be used without these details.
A client typically engages a pharmacy benefits manager (PBM), to offer a drug program. Clients include government agencies (e.g., Federal Government agencies, the Department of Defense and the Centers for Medicare & Medicaid Services and state agencies), middle market businesses, large national employers, insurance companies that have carved the drug benefit out, and other organizations. Participation or membership in a client’s drug benefit program allows for prescription drug access based on pricing, pharmacy selection, rebates and discounts, as well as other terms.
The client’s offered drug benefits program could be an independent drug benefit or part of a health benefit offered by a company that offers PBM services directly to the company.
The following are some of the operations that the PBM might perform. The member, or someone acting on his behalf, attempts to get a prescription drug at a pharmacy that sells drugs. This is where the member can buy drugs from a pharmacist or technician. A pharmacy can be associated only with one retail pharmacy or it can be part of a chain that has multiple retail pharmacies. The pharmacy submits a claim for the prescription drug to the PBM. The PBM then performs a number of adjudication operations, including verifying eligibility, reviewing the formulary to determine the appropriate co-pay, insurance, and deductible for prescription drugs, as well as performing a drug usage review (DUR), on the member. After performing the above operations, the PBM provides a response to pharmacy. These adjudications usually occur before the copay is received or the prescription drug is dispensed. The operations can be performed simultaneously, substantially simultaneously or in a different order. Additionally, the adjudication process may include more or less adjudication functions.
The client, or typically the PBM for the client, ultimately reimburses the pharmacy for filling a prescription drug once the drug has been successfully adjudicated. The type of pharmacy network that the pharmacy is part of may have an impact on the amount of reimbursement the client or PBM pays to the pharmacy. The reimbursement amount may also be determined by other factors, such as the type of pharmacy network. If the PBM reimburses the client’s pharmacy, the PBM might bill the client for reimbursement and, more often, for services rendered by the PBM in managing the drug benefit program and adjudicating claims. The amount the PBM bills the client may depend at least partially on the amount of reimbursement that was paid to the pharmacy and the type or network of pharmacies in which the pharmacy is included. The amount billed may also be determined by other factors.
In certain embodiments, members of drug benefit programs may designate a specific pharmacy or a particular pharmacist as their preferred pharmacy. A member may designate a particular pharmacy or pharmacist as the preferred pharmacy. This could be used primarily for filling prescriptions and other related services. The member could designate a pharmacy as their preferred pharmacy. This could be a pharmacy that is convenient to the member or a pharmacy with which they have an affinity.
In some instances, benefits the member receives from using the preferred pharmacy or preferred pharmacist may be different than the benefits the member receives from using another pharmacy or pharmacist that has not been designated as the member’s preferred pharmacy. The member might be required to pay a lower prescription co-pay at his preferred pharmacy or with his preferred pharmacist than the member would have to pay at any other non-preferred pharmacies or pharmacists. The benefits the member might receive at the preferred pharmacy include higher coverage under the drug benefit plan for vaccinations, complimentary or lower-priced therapy consultations, and complimentary or lower-priced screenings (e.g. blood pressure screenings or blood sugar screenings or cholesterol screenings). Other benefits and/or benefits may also be available to the member when they use the preferred pharmacy or pharmacist. These benefits may differ from the benefits the member receives when using another pharmacy or pharmacist (i.e. not the preferred).
In certain embodiments, the PBM that provides the drug benefit program to the member may be eligible for lower reimbursements rates for prescriptions or other services under the drug benefits program from the preferred pharmacist associated with it and/or the preferred pharmacy. The pharmacy might be willing to negotiate lower reimbursement rates for members who have designated the pharmacy as their preferred pharmacy. This is because the member may use the pharmacy for products or services other than prescriptions. A member’s affinity for the pharmacist (e.g. based on their choice of pharmacy as preferred pharmacy) may make it more likely that they will use the pharmacy to obtain over-the-counter medications and services such as health screenings (e.g. blood pressure screenings or blood sugar screenings or cholesterol screenings). Some embodiments allow the member to develop a stronger relationship with the pharmacist. This may increase trust and help the member adhere to a prescribed drug treatment plan. The member may also designate the pharmacy as his preferred pharmacy. This could increase the probability that the pharmacy will be used for most of his prescriptions. If multiple members have chosen the same pharmacy to be their preferred pharmacy within a single drug benefit plan and/or across multiple drug benefit programs sponsored by the PBM, this may allow the PBM negotiate a lower reimbursement rate for the pharmacy.
FIG. “FIG. An example embodiment of how a discount may be applied to prescription drugs is the system 100. The system 100 has a patient device (102) in communication with a benefit manager device (106) over a network of 104. A pharmacy device may be included in the system.
A device operator uses the patient device 102. A member of a drug benefits program may be the device operator. The device operator could be a member of a drug benefit program. Parents, guardians, and caregivers are examples of such people. While some embodiments in which the device operator is the member may be shown, it should not be assumed that this operator could be any other person than the member.
The patient device 102 may be used by a member to designate a preferred pharmacy. The patient device 102 can be used as a standalone device to allow a member to designate a preferred pharmacist. It may also be used in conjunction with other devices that provide functionality beyond enabling the member’s preferred pharmacy designation. The patient device 102 may include a set top box (STB), receiver card, a mobile phone, a personal assistant (PDA), and a display device. Other devices can also be used. The computing system may be used in some embodiments. The patient device 102 could include a mobile electronic device, such as an IPHONE or IPAD by Apple, Inc., mobile electronics powered by ANDROID, Inc., and BLACKBERRY by Research In Motion Limited. Other computing devices may be included in the patient device 102, including netbook computing, gaming, desktop computing, and notebook computing devices. You may also use other types of electronic devices.
The network 104 through which the patient device (102) communicates with the benefit manger device (106), and/or pharmacy device (108) may include, for example, Mobile Communications network, code division multiple access network (CDMA network), 3rd Generation Partnership Project (3GPP), Internet Protocol (IP), Wireless Application Protocol (WAP), WiFi network, an IEEE 802.11 standards network as well as various combinations thereof. Network 104 could also include optical communications. Other wired and wireless networks, both existing and later developed, may also be used. The network 104 could include a prescribing system such as Surescripts’ electronic prescribing network in Arlington, Va.
The benefit manager device (106) is a device that is operated by an entity responsible at least partially for managing a drug benefit plan. Although the benefit manager device106 is usually operated by a PBM entity, other entities can operate the device 106 on their behalf, the PBM or for another entity. A PBM that provides drug benefits may, in some instances, also provide additional benefits such as a health benefit or a vision benefit or a well-being benefit, radiology benefit, pet care benefit, insurance benefit, long-term care benefit, nursing home benefit, etc.
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 submits a claim for the prescription drug to the PBM along with the member’s co-pay. The PBM can perform adjudication operations such as verifying eligibility, reviewing the prescription formulary to determine the appropriate co-pay, insurance, and deductible for the prescription drugs, and performing DURs on the member. After performing the above operations, the PBM provides a response to pharmacy. The client, or the PBM for the client, ultimately reimburses the pharmacy for filling prescription drugs when they were approved. These adjudications usually occur before the copay is received or the prescription drug is dispensed. The operations can be performed simultaneously, substantially simultaneously or in a different order. Additionally, adjudication may include more or less operations.
The patient device102 could be in a client/server relationship with benefit manager device106, or a peer to peer relationship with benefit manager device106.
The pharmacy device number 108 could be associated with a retail location. This could include an exclusive pharmacy location, general sales stores with a pharmacy or general sales stores with a pharmacy. The pharmacy may use the pharmacy device 108 to submit the claim to a PBM for adjudication. In some cases, the pharmacy device may also allow information exchange between the PBM and the pharmacy. This may be used to, for instance, allow members to share their drug histories.
