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 SYNAGIS using software dedicated to processing requests for prescriptions solely for SYNAGIS, the method comprising:
 (A) obtaining with a user interface device of a provider system prescription information for SYNAGIS for a patient, the user interface device comprising a user input device and a display device, the software causing the display device to display an electronic form dedicated to receiving the prescription information solely for SYNAGIS, wherein the prescription information comprises (i) information identifying the patient, and (ii) a prescription for an amount of SYNAGIS;   (B) receiving with the user interface device patient clinical information, the software causing the display device to display an electronic form dedicated to receiving the patient clinical information relevant to SYNAGIS, wherein the patient clinical information comprises a plurality of determinants that contribute to a basis for authorizing or denying coverage to said patient for SYNAGIS, the electronic form comprising blocks for receiving via the user input device determinants comprising the patient's gestational age and an indication of whether the patient spent time in a neonatal intensive care unit (NICU), and wherein at least one determinant is not a standardized code;   (C) storing the prescription information and the patient clinical information in a non-transitory computer-readable medium;   (D) requesting coverage for the patient for SYNAGIS by sending the prescription information and the patient clinical information from the provider system 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 SYNAGIS, 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) displaying with the display device the coverage decision made by the pharmacy.   
     
     
         2 . The method of  claim 1 , wherein the electronic form dedicated to receiving patient clinical information relevant to SYNAGIS comprises one or more blocks for receiving via the user input device 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 electronic form dedicated to receiving patient clinical information relevant to SYNAGIS comprises one or more blocks for receiving via the user input device a categorical indication as to whether the patient has congenital heart disease wherein, when the patient is indicated to have congenital heart disease, the electronic form comprises blocks for entering via the user input device 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 electronic form dedicated to receiving patient clinical information relevant to SYNAGIS comprises one or more blocks for receiving via the user input device a categorical indication as to whether the patient has a chronic pulmonary disease wherein, when the patient is indicated to have the chronic pulmonary disease, the electronic form comprises blocks for entering via the user input device the group of determinants further comprising
 (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 SYNAGIS is denied when the patient is more than two years old. 
     
     
         6 . The method of  claim 1 , wherein the electronic form dedicated to receiving patient clinical information relevant to SYNAGIS comprises at least two blocks for receiving via the user input device a corresponding 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 electronic form dedicated to receiving patient clinical information relevant to SYNAGIS comprises at least five blocks for receiving via the user input device a corresponding 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 electronic form dedicated to receiving patient clinical information relevant to SYNAGIS comprises one or more blocks for receiving via the user input device 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 electronic form dedicated to receiving patient clinical information relevant to SYNAGIS comprises five or more blocks for receiving via the user input device a corresponding 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 requesting (D) comprises sending the prescription information and the patient clinical information from the provider system 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 requesting (D) comprises sending the prescription information and the patient clinical information to the pharmacy by FAX or email. 
     
     
         14 . The method of  claim 1 , wherein the electronic form dedicated to receiving prescription information for SYNAGIS for the patient further includes one or more blocks for receiving via the user input device 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 electronic form dedicated to receiving prescription information for SYNAGIS for the patient further includes six or more blocks for receiving via the user input device a corresponding 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 requesting (D) is done without human intervention. 
     
     
         17 . The method of  claim 1 , wherein each determinant is not a standardized code. 
     
     
         18 . A non-transitory computer-readable medium storing a computer program product, executable by a computer comprising a user interface device having a user input device and a display device, to process a request for a prescription solely for SYNAGIS, the computer program product comprising instructions for causing the computer to perform the steps of:
 (A) obtaining with the user interface device prescription information for SYNAGIS for a patient, the instructions causing the display device to display an electronic form dedicated to receiving the prescription information solely for SYNAGIS, wherein the prescription information comprises (i) information identifying the patient, and (ii) a prescription for an amount of SYNAGIS;   (B) receiving with the user interface device patient clinical information, the instructions causing the display device to display an electronic form dedicated to receiving the patient clinical information relevant to SYNAGIS, wherein the patient clinical information comprises a plurality of determinants that contribute to a basis for authorizing or denying coverage to said patient for SYNAGIS, the electronic form comprising blocks for receiving via the user input device determinants comprising the patient's gestational age and an indication of whether the patient spent time in a neonatal intensive care unit (NICU), and wherein at least one determinant is not a standardized code;   (C) storing the prescription information and the patient clinical information in a non-transitory computer-readable medium;   (D) requesting approval for the patient for SYNAGIS by sending the prescription information and the patient clinical information from the computer 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 SYNAGIS, 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) displaying with the display device the coverage decision made by the pharmacy.   
     
     
         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 user interface device comprising a user input device and a display device;   a processor coupled to the user interface device; and   a memory, coupled to the processor, the memory storing a module comprising instructions for causing the processor to perform the steps of:   (A) obtaining with the user interface device prescription information for SYNAGIS for a patient, the instructions causing the display device to display an electronic form dedicated to receiving the prescription information solely for SYNAGIS, wherein the prescription information comprises (i) information identifying the patient and (ii) a prescription for an amount of SYNAGIS;   (B) receiving with the user interface device patient clinical information, the instructions causing the display device to display an electronic form dedicated to receiving the patient clinical information relevant to SYNAGIS, wherein the patient clinical information comprises a plurality of determinants that contribute to a basis for authorizing or denying coverage to said patient for SYNAGIS, the electronic form comprising blocks for receiving via the user input device determinants comprising the patient's gestational age and an indication of whether the patient spent time in a neonatal intensive care unit (NICU), and wherein at least one determinant is not a standardized code;   (C) storing the prescription information and the patient clinical information in a non-transitory computer-readable medium;   (D) requesting approval for the patient for SYNAGIS by sending the prescription information and the patient clinical information from the apparatus 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 SYNAGIS, 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) displaying with the display device the coverage decision made by the pharmacy.   
     
     
         20 - 45 . (canceled)