Systems and methods for processing requests for pharmaceuticals that require insurer preapproval

Abstract

Systems, methods, and apparatus for managing patients in need of a predetermined pharmaceutical that requires preauthorization based upon patient clinical data are provided. Prescription information is obtained for each respective patient. Such information includes an identity of the patients and amounts of the pharmaceutical that has been prescribed to the patients. Further, clinical information associated with each patient is received. The clinical information one or more determinants that each contributes to providing a basis for authorizing or denying patient coverage for the pharmaceutical. At least one determinant in the one or more determinants is not a standardized code. Coverage for a patient for the predetermined pharmaceutical is requested by transmitting the prescription and clinical information to a specialty pharmaceutical distributor at a remote location. A grant or denial of coverage for the patient is then received from the remote location and stored in an electronic record associated with the patient.

1 . A method for processing a request for a prescription for a predetermined pharmaceutical that requires preauthorization based upon clinical information of a patient, the method comprising:
 (A) obtaining prescription information for the patient, wherein the prescription information comprises (i) an identity of the patient, (ii) an amount of the predetermined pharmaceutical, and (iii) a prescription for the amount of the predetermined pharmaceutical;   (B) receiving patient clinical information, wherein the patient clinical information comprises one or more determinants of the patient and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to said patient for said predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;   (C) storing the prescription information and the patient clinical information in electronic form;   (D) sending the prescription information and the patient clinical information to a pharmacy that is configured to use the prescription information and the patient clinical information to make a coverage decision as to whether to grant coverage to said patient for said predetermined pharmaceutical, wherein said coverage decision made by the pharmacy is based upon (i) a set of guidelines provided by an insurer of the patient, (ii) the prescription information, and (iii) the patient clinical information; and   (E) communicating the coverage decision to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, or a local or remote computer system; or displaying the coverage decision in a user readable form.   
   
   
       2 . The method of  claim 1 , wherein the patient clinical information comprises at least one determinant from the group of determinants consisting of a gestational age of the patient,
 a weight of the patient,   a categorical indication as to whether the patient has congenital heart disease,   a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,   a categorical indication as to whether the patient has a chronic pulmonary disease, and   a categorical indication as to whether the patient has a congenital anomaly of the respiratory system.   
   
   
       3 . The method of  claim 1 , wherein the patient clinical information comprises a categorical indication as to whether the patient has congenital heart disease wherein, when the patient has congenital heart disease, the group of determinants further comprises a categorical indication as to whether the patient has
 (i) a moderate pulmonary hypertension or a severe pulmonary hypertension,   (ii) an identity of a medication that is being given to the patient for the congenital heart disease, and   (iii) a date when the medication for the congenital heart disease was administered to the patient.   
   
   
       4 . The method of  claim 1 , wherein the patient clinical information comprises a categorical indication as to whether the patient has a chronic pulmonary disease wherein, when the patient has the chronic pulmonary disease, the group of determinants further comprises
 (i) a categorical indication as to whether the patient receives supplemental oxygen,   (ii) a categorical indication as to whether the patient receives a corticosteroid,   (iii) a categorical indication as to whether the patient receives a diuretic, and   (iv) a categorical indication as to whether the patient receives a bronchodilator.   
   
   
       5 . The method of  claim 1 , wherein said coverage decision comprises determining an age of the patient from the patient clinical information or the prescription information and wherein coverage to said patient for said predetermined pharmaceutical is denied when the patient is more than two years old. 
   
   
       6 . The method of  claim 1 , wherein the patient clinical information comprises at least two determinants from the group of determinants consisting of
 a gestational age of the patient,   a weight of the patient,   a categorical indication as to whether the patient has congenital heart disease,   a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,   a categorical indication as to whether the patient has a chronic pulmonary disease, and   a categorical indication as to whether the patient has a congenital anomaly of the respiratory system.   
   
   
       7 . The method of  claim 1 , wherein the patient clinical information comprises at least five determinants from the group of determinants consisting of
 a gestational age of the patient,   a weight of the patient,   a categorical indication as to whether the patient has congenital heart disease,   a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,   a categorical indication as to whether the patient has a chronic pulmonary disease, and   a categorical indication as to whether the patient has a congenital anomaly of the respiratory system.   
   
   
       8 . The method of  claim 1 , wherein the patient clinical information comprises one or more risk factors selected from the group consisting of
 a categorical indication as to whether the patient has a school-age sibling,   a categorical indication as to whether the patient has been subjected to an air pollutant,   a categorical indication as to whether the patient attends day care,   a categorical indication as to whether the patient has severe neuromuscular disease,   a categorical indication as to whether the patient is subject to crowded living conditions,   a categorical indication as to whether the patient had a birth weight of less than 2500 grams,   a categorical indication as to whether the patient was part of a multiple birth,   a categorical indication as to whether there is a history of asthma in the patient's family,   a categorical indication as to whether the patient suffers from a congenital abnormality or airway, and   a categorical indication as to whether the patient has been exposed to tobacco smoke.   
   
   
       9 . The method of  claim 1 , wherein the patient clinical information comprises five or more risk factors selected from the group consisting of
 a categorical indication as to whether the patient has a school-age sibling,   a categorical indication as to whether the patient has been subjected to an air pollutant,   a categorical indication as to whether the patient attends day care,   a categorical indication as to whether the patient has severe neuromuscular disease,   a categorical indication as to whether the patient is subject to crowded living conditions,   a categorical indication as to whether the patient had a birth weight of less than 2500 grams,   a categorical indication as to whether the patient was part of a multiple birth,   a categorical indication as to whether there is a history of asthma in the patient's family,   a categorical indication as to whether the patient suffers from a congenital abnormality or airway, and   a categorical indication as to whether the patient has been exposed to tobacco smoke.   
   
   
       10 . The method of  claim 1 , wherein the sending (D) comprises sending the prescription information and the patient clinical information to a remote computer associated with the pharmacy in a packet-based form over a wide area network or Internet. 
   
   
       11 . The method of  claim 10 , wherein the prescription information and the clinical information is sent in a secure manner over the wide area network or Internet. 
   
   
       12 . The method of  claim 10 , wherein the prescription information and the patient clinical information is sent using the Hypertext Transport Protocol over a secure socket layer. 
   
   
       13 . The method of  claim 1 , wherein the sending (D) comprises sending the prescription information and the patient clinical information to the pharmacy by FAX, mail, or hand delivery. 
   
   
       14 . The method of  claim 1 , wherein the prescription information for the patient further includes one or more insurance information elements selected from the group consisting of
 an identification of the primary insurer for the patient,   a primary cardholder name,   a primary cardholder social security number,   a primary policy number,   a primary insurer telephone number,   a primary employer,   a primary group number,   an identification of a secondary insurer for the patient,   a secondary cardholder name,   a secondary cardholder social security number,   a secondary policy number,   a secondary insurer telephone number, a secondary employer, and   a secondary group number.   
   
   
       15 . The method of  claim 1 , wherein the prescription information for the patient further includes six or more insurance information elements selected from the group consisting of
 an identification of the primary insurer for the patient,   a primary cardholder name,   a primary cardholder social security number,   a primary policy number, a primary insurer telephone number,   a primary employer,   a primary group number,   an identification of a secondary insurer for the patient,   a secondary cardholder name,   a secondary cardholder social security number,   a secondary policy number,   a secondary insurer telephone number,   a secondary employer, and   a secondary group number.   
   
   
       16 . The method of  claim 1 , wherein the sending (D) and the communicating (E) are each done without human intervention. 
   
   
       17 . The method of  claim 1 , wherein each determinant in the one or more determinants is not a standardized code. 
   
   
       18 . A computer-readable medium storing a computer program product, executable by a computer, to process a request for a prescription for a predetermined pharmaceutical that requires preauthorization based upon clinical data of a patient, the computer program product comprising instructions for:
 (A) obtaining prescription information for the patient, wherein the prescription information comprises (i) an identity of the patient, (ii) an amount of the predetermined pharmaceutical, and (iii) a prescription for the amount of the predetermined pharmaceutical;   (B) receiving patient clinical information, wherein the patient clinical information comprises one or more determinants of the patient and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to said patient for said predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;   (C) storing the prescription information and the patient clinical information in electronic form;   (D) sending the prescription information and the patient clinical information to a pharmacy that is configured to use the prescription information and the patient clinical information to make a coverage decision as to whether to grant coverage to said patient for said predetermined pharmaceutical, wherein said coverage decision made by the pharmacy is based upon (i) a set of guidelines provided by an insurer of the patient, (ii) the prescription information, and (iii) the patient clinical information; and   (E) communicating the coverage decision to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, or a local or remote computer system; or displaying the coverage decision in a user readable form.   
   
   
       19 . An apparatus for processing a request for a prescription for a predetermined pharmaceutical that requires preauthorization based upon clinical data of a patient, the apparatus comprising:
 a processor; and   a memory, coupled to the processor, the memory storing a module comprising instructions for:   (A) obtaining prescription information for the patient, wherein the prescription information comprises (i) an identity of the patient, (ii) an amount of the predetermined pharmaceutical, and (iii) a prescription for the amount of the predetermined pharmaceutical;   (B) receiving patient clinical information, wherein the patient clinical information comprises one or more determinants of the patient and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to said patient for said predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;   (C) storing the prescription information and the patient clinical information in electronic form;   (D) sending the prescription information and the patient clinical information to a pharmacy that is configured to use the prescription information and the patient clinical information to make a coverage decision as to whether to grant coverage to said patient for said predetermined pharmaceutical, wherein said coverage decision made by the pharmacy is based upon (i) a set of guidelines provided by an insurer of the patient, (ii) the prescription information, and (iii) the patient clinical information; and   (E) communicating the coverage decision to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, or a local or remote computer system; or displaying the coverage decision in a user readable form.   
   
   
       20 . A method for managing a plurality of patients that are each in need of a predetermined pharmaceutical that requires preauthorization based upon patient clinical data, the method comprising:
 (A) obtaining prescription information for each respective patient in the plurality of patients, wherein the prescription information comprises an identity of the respective patient and an amount of the predetermined pharmaceutical that has been prescribed to the patient;   (B) receiving clinical information associated with each respective patient in the plurality of patients, wherein the clinical information for each respective patient comprises one or more determinants and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to the respective patient for the predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;   (C) storing the prescription information and the clinical information in electronic form;   (D) requesting coverage for a patient in the plurality of patients for the predetermined pharmaceutical by transmitting the prescription information and the clinical information to a specialty pharmaceutical distributor at a remote location by electronic means; and   (E) communicating a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, a local or remote computer system, or a record associated with the patient; or displaying a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical in a user readable form.   
   
   
       21 . The method of  claim 20 , wherein the clinical information for the patient comprises at least one determinant from the group of determinants consisting of
 a gestational age of the patient,   a weight of the patient,   a categorical indication as to whether the patient has congenital heart disease,   a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,   a categorical indication as to whether the patient has a chronic pulmonary disease, and   a categorical indication as to whether the patient has a congenital anomaly of the respiratory system.   
   
   
       22 . The method of  claim 20 , wherein the clinical information for the patient comprises a categorical indication as to whether the patient has congenital heart disease wherein, when the patient has congenital heart disease, the group of determinants further comprises:
 (i) a categorical indication as to whether the patient has a moderate pulmonary hypertension or a severe pulmonary hypertension,   (ii) an identity of a medication that is being given to the patient for the congenital heart disease, and   (iii) a date when the medication for the congenital heart disease was administered to the patient.   
   
   
       23 . The method of  claim 20 , wherein the clinical information for the patient comprises a categorical indication as to whether the patient has a chronic pulmonary disease wherein, when the patient has the chronic pulmonary disease, the group of determinants further comprises:
 (i) a categorical indication as to whether the patient receives supplemental oxygen,   (ii) a categorical indication as to whether the patient receives a corticosteroid,   (iii) a categorical indication as to whether the patient receives a diuretic, and   (iv) a categorical indication as to whether the patient receives a bronchodilator.   
   
   
       24 . The method of  claim 20 , wherein the requesting (D) further comprises providing an age of the patient and wherein the communicating (E) comprises receiving a denial of coverage for said patient when the patient is more than two years old. 
   
   
       25 . The method of  claim 20 , wherein the clinical information for the patient comprises at least two determinants from the group of determinants consisting of:
 a gestational age of the patient,   a weight of the patient,   a categorical indication as to whether the patient has congenital heart disease,   a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,   a categorical indication as to whether the patient has a chronic pulmonary disease, and   a categorical indication as to whether the patient has a congenital anomaly of the respiratory system.   
   
   
       26 . The method of  claim 20 , wherein the clinical information for the patient comprises at least five determinants from the group of determinants consisting of:
 a gestational age of the patient,   a weight of the patient,   a categorical indication as to whether the patient has congenital heart disease,   a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,   a categorical indication as to whether the patient has a chronic pulmonary disease, and   a categorical indication as to whether the patient has a congenital anomaly of the respiratory system.   
   
   
       27 . The method of  claim 20 , wherein the clinical information for the patient comprises one or more risk factors selected from the group consisting of:
 a categorical indication as to whether the patient has a school-age sibling,   a categorical indication as to whether the patient has been subjected to an air pollutant,   a categorical indication as to whether the patient attends day care,   a categorical indication as to whether the patient has severe neuromuscular disease,   a categorical indication as to whether the patient is subjected to crowded living conditions, a categorical indication as to whether the patient had a birth weight of less than 2500 grams,   a categorical indication as to whether the patient was part of a multiple birth,   a categorical indication as to whether there is a history of asthma in the patient's family,   a categorical indication as to whether the patient suffers from a congenital abnormality or airway, and   a categorical indication as to whether the patient has been exposed to tobacco smoke.   
   
   
       28 . The method of  claim 20 , wherein the clinical information for the patient comprises five or more risk factors selected from the group consisting of:
 a categorical indication as to whether the patient has a school-age sibling,   a categorical indication as to whether the patient has been subjected to an air pollutant,   a categorical indication as to whether the patient attends day care,   a categorical indication as to whether the patient has severe neuromuscular disease,   a categorical indication as to whether the patient is subjected to crowded living conditions,   a categorical indication as to whether the patient had a birth weight of less than 2500 grams,   a categorical indication as to whether the patient was part of a multiple birth,   a categorical indication as to whether there is a history of asthma in the patient's family,   a categorical indication as to whether the patient suffers from a congenital abnormality or airway, and   a categorical indication as to whether the patient has been exposed to tobacco smoke.   
   
   
       29 . The method of  claim 20 , wherein the requesting (D) comprises transmitting the prescription information and the clinical information for the patient to a remote computer in a packet-based form over a wide area network or Internet. 
   
   
       30 . The method of  claim 29 , wherein the prescription information and the clinical information for the patient is transmitted in a secure manner over the wide area network or Internet. 
   
   
       31 . The method of  claim 29 , wherein the prescription information and the clinical information for the patient is transmitted using the Hypertext Transport Protocol over a secure socket layer. 
   
   
       32 . The method of  claim 20 , wherein the requesting (D) comprises sending the prescription information and the patient clinical information to the pharmacy by FAX, mail, or hand delivery. 
   
   
       33 . The method of  claim 20 , wherein the prescription information for the patient further includes one or more insurance information elements selected from the group consisting of:
 an identification of the primary insurer for the patient,   a primary cardholder name,   a primary cardholder social security number,   a primary policy number,   a primary insurer telephone number,   a primary employer, a primary group number,   an identification of a secondary insurer for the patient,   a secondary cardholder name,   a secondary cardholder social security number,   a secondary policy number,   a secondary insurer telephone number,   a secondary employer, and   a secondary group number.   
   
   
       34 . The method of  claim 20 , the method further comprising storing in electronic form an identity of a specialty pharmacy distributor for a patient in the plurality of patients. 
   
   
       35 . The method of  claim 20 , the method further comprising storing in electronic form an identity of a drug benefit provider for a patient in the plurality of patients. 
   
   
       36 . The method of  claim 20 , wherein the clinical information for the patient comprises a categorical indication as to whether the patient spent time in a neonatal intensive care unit. 
   
   
       37 . The method of  claim 20 , wherein the prescription information for the patient further comprises an address where the predetermined pharmaceutical is to be shipped. 
   
   
       38 . The method of  claim 20 , the method further comprising:
 (i) generating a schedule for when the predetermined pharmaceutical is to be administered to the patient;   (ii) storing the schedule in a patient record associated with the patient; and   (iii) communicating the schedule to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, a local or remote computer system, or a record associated with the patient; or displaying the schedule in a user readable form.   
   
   
       39 . The method of  claim 38 , the method further comprising:
 (iv) sending an alert to a care practitioner or the patient at a time prior to when the patient is due for a dosage of the predetermined pharmaceutical as determined by the schedule.   
   
   
       40 . The method of  claim 20 , the method further comprising storing, in electronic form, an identity of each practitioner in a medical practitioner group that is responsible for making requests for prescriptions for said predetermined pharmaceutical for any of the patients in the plurality of patients. 
   
   
       41 . The method of  claim 20 , the method further comprising storing, in electronic form, the package insert for the predetermined pharmaceutical. 
   
   
       42 . The method of  claim 20 , the method further comprising storing, in electronic form, of safety information for the predetermined pharmaceutical. 
   
   
       43 . The method of  claim 20 , wherein each determinant in the one or more determinants is not a standardized code. 
   
   
       44 . A computer-readable medium storing a computer program product, executable by a computer, to manage a plurality of patients that are each in need of a predetermined pharmaceutical that requires preauthorization based upon patient clinical data, the computer program product comprising instructions for:
 (A) obtaining prescription information for each respective patient in the plurality of patients, wherein the prescription information comprises an identity of the respective patient and an amount of the predetermined pharmaceutical that has been prescribed to the patient;   (B) receiving clinical information associated with each respective patient in the plurality of patients, wherein the clinical information for each respective patient comprises one or more determinants and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to the respective patient for the predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;   (C) storing the prescription information and the clinical information in electronic form;   (D) requesting coverage for a patient in the plurality of patients for the predetermined pharmaceutical by transmitting the prescription information and the clinical information to a specialty pharmaceutical distributor at a remote location by electronic means; and   (E) communicating a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, a local or remote computer system, or a record associated with the patient; or displaying a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical in a user readable form.   
   
   
       45 . An apparatus for managing a plurality of patients that are each in need of a predetermined pharmaceutical that requires preauthorization based upon patient clinical data, the apparatus comprising:
 a processor; and   a memory, coupled to the processor, the memory storing a module comprising instructions for:   (A) obtaining prescription information for each respective patient in the plurality of patients, wherein the prescription information comprises an identity of the respective patient and an amount of the predetermined pharmaceutical that has been prescribed to the patient;   (B) receiving clinical information associated with each respective patient in the plurality of patients, wherein the clinical information for each respective patient comprises one or more determinants and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to the respective patient for the predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;   (C) storing the prescription information and the clinical information in electronic form;   (D) requesting coverage for a patient in the plurality of patients for the predetermined pharmaceutical by transmitting the prescription information and the clinical information to a specialty pharmaceutical distributor at a remote location by electronic means; and   (E) communicating a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, a local or remote computer system, or a record associated with the patient; or displaying a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical in a user readable form.