Systems and methods for simulating a change to a prescription drug plan

Abstract

Systems and methods for simulating a change to a prescription drug plan may be provided. In response to receiving a request to simulate the change to the prescription drug plan, a prescription drug spend and/or trend application may retrieve data related to the prescription drug plan from a database. A model that includes a plurality of calculations to simulate the change may be applied to the retrieved data A user computing device may be provided with an indication of an impact on the prescription drug plan responsive to the at least one change based at least in part on the application of the model to the retrieved data. The modeling of the change may be related, for example, to an option to reduce spend and/or trend as determined by the spend and/or trend application.

1 . A method for modeling an impact of an option for reducing at least one of spend and trend for a prescription drug plan, comprising:
 receiving a request from a user computing device to process the at least one of spend and trend for the prescription drug plan;   in response to receiving the request to process the at least one of spend and trend, retrieving data related to the prescription drug plan from a database;   processing the at least one of spend and trend for the prescription drug plan using the retrieved data;   determining whether at least one option to reduce the at least one of spend and trend for the prescription drug plan is available;   if the at least one option is available, providing an indication of the at least one option to the user computing device, wherein the at least one option comprises at least one change to the prescription drug plan;   receiving a request to simulate the at least one change to the prescription drug plan from the user computing device;   in response to receiving the request, retrieving data related to the prescription drug plan from the database;   applying a model to the retrieved data, wherein the model comprises a plurality of calculations to simulate the at least one change to the prescription drug plan, and wherein:
 if the at least one change comprises a change to a financial aspect of the prescription drug plan, the applied model is a financial model; and 
 if the at least one change comprises a change to a clinical aspect of the prescription drug plan, the applied model is a clinical model; and 
   providing the user computing device with an indication of at least one of a financial and member impact on the prescription drug plan responsive to the at least one change based at least in part on the application of the model to the retrieved data.   
     
     
         2 . The method of  claim 1 , wherein the financial model comprises at least one of:
 a formulary options model comprising a plurality of calculations that determine a rebate impact of a change to at least one of formulary content and co-pays for the prescription drug plan;   a therapeutic class optimizer model comprising a plurality of calculations that estimate a rebate impact and a net cost impact of moving a particular drug on or off a formulary of the prescription drug plan for one or more therapeutic classes;   a specialty model comprising a plurality of calculations that determine an estimated drug spend impact and an estimated discount impact associated with implementing a specialty pharmacy offering;   a Medicare coordination of benefits model comprising a plurality of calculations that determine an estimated financial impact of implementing a Medicare Part B subrogation program for home delivery claims;   an inclusions/exclusions model comprising a plurality of calculations that determine an estimated impact of including or excluding a particular drug in the prescription drug plan that is typically considered for exclusion from coverage;   a member cost share model comprising a plurality of calculations that determine an impact of changes to at least one of open and incentive co-pay prescription drug plan structures comprising a plurality of tiers;   a retail refill allowance model comprising a plurality of calculations that determine an impact of a stand-alone retail refill allowance at a user specified threshold;   a home delivery advantage model comprising a plurality of calculations that determine an impact of a stand-alone home delivery advantage comprising retail and home delivery co-pay alignment;   a member pay the difference model comprising a plurality of calculations that determine an impact of at least one of a managed and sensitive member pay the difference program;   a generic bundle model comprising a plurality of sub-models related to generic drug utilization including at least one of dose duration, step therapy, incentive co-pay, and member pay the difference;   an out of pocket maximum model comprising a plurality of calculations that determine an impact of an out of pocket maximum both with and without a change to deductible or co-pay;   a deductibles model comprising a plurality of calculations that determine an impact of deductibles both with and without a change to out of pocket cost and co-pay;   a patient safety program model comprising a plurality of calculations that determine an estimated financial impact of implementing a patient safety program for the prescription drug plan;   a benefit cap model comprising a plurality of calculations that determine an impact of a benefit cap for the prescription drug plan; and   a retail access density model comprising a plurality of calculations that determine a member impact of removing at least one chain prescription drug retailer from the prescription drug plan.   
     
     
         3 . The method of  claim 1 , wherein the clinical model comprises at least one of:
 a dose optimization model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing dose optimization rules;   a quantity per dispensing event model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing quantity per dispensing event rules;   a smart rules model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing smart coverage authorization rules;   a traditional prior authorization model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing traditional prior authorization rules; and   a new drug events model comprising a plurality of calculations that determine an estimated impact of a status change for a particular drug, the status change comprising at least one of an expiration of a patent for the drug, a new indication for the drug, a shift of the drug from prescription to over-the-counter, an introduction of the drug to the marketplace, and a withdrawal of the drug from the marketplace.   
     
     
         4 . A system for modeling an impact of an option for reducing at least one of spend and trend for a prescription drug plan, comprising:
 a server in communication with a user computing device and a database, wherein the server is configured to:
 receive a request from the user computing device to process the at least one of spend and trend for the prescription drug plan; 
 in response to receipt of the request to process the at least one of spend and trend, retrieve data related to the prescription drug plan from the database; 
 process the at least one of spend and trend for the prescription drug plan using the retrieved data; 
 determine whether at least one option to reduce the at least one of spend and trend for the prescription drug plan is available; 
 if the at least one option is available, provide an indication of the at least one option to the user computing device, wherein the at least one option comprises at least one change to the prescription drug plan; 
 receive a request to simulate the at least one change to the prescription drug plan from the user computing device; 
 in response to receipt of the request, retrieve data related to the prescription drug plan from the database; 
 apply a model to the retrieved data, wherein the model comprises a plurality of calculations to simulate the at least one change to the prescription drug plan, and wherein:
 if the at least one change comprises a change to a financial aspect of the prescription drug plan, the applied model is a financial model; and 
 if the at least one change comprises a change to a clinical aspect of the prescription drug plan, the applied model is a clinical model; and 
 
 provide the user computing device with an indication of at least one of a financial and member impact on the prescription drug plan responsive to the at least one change based at least in part on the application of the model to the retrieved data. 
   
     
     
         5 . The system of  claim 4 , wherein the financial model comprises at least one of:
 a formulary options model comprising a plurality of calculations that determine a rebate impact of a change to at least one of formulary content and co-pays for the prescription drug plan;   a therapeutic class optimizer model comprising a plurality of calculations that estimate a rebate impact and a net cost impact of moving a particular drug on or off a formulary of the prescription drug plan for one or more therapeutic classes;   a specialty model comprising a plurality of calculations that determine an estimated drug spend impact and an estimated discount impact associated with implementing a specialty pharmacy offering;   a Medicare coordination of benefits model comprising a plurality of calculations that determine an estimated financial impact of implementing a Medicare Part B subrogation program for home delivery claims;   an inclusions/exclusions model comprising a plurality of calculations that determine an estimated impact of including or excluding a particular drug in the prescription drug plan that is typically considered for exclusion from coverage;   a member cost share model comprising a plurality of calculations that determine an impact of changes to at least one of open and incentive co-pay prescription drug plan structures comprising a plurality of tiers;   a retail refill allowance model comprising a plurality of calculations that determine an impact of a stand-alone retail refill allowance at a user specified threshold;   a home delivery advantage model comprising a plurality of calculations that determine an impact of a stand-alone home delivery advantage comprising retail and home delivery co-pay alignment;   a member pay the difference model comprising a plurality of calculations that determine an impact of at least one of a managed and sensitive member pay the difference program;   a generic bundle model comprising a plurality of sub-models related to generic drug utilization including at least one of dose duration, step therapy, incentive co-pay, and member pay the difference;   an out of pocket maximum model comprising a plurality of calculations that determine an impact of an out of pocket maximum both with and without a change to deductible or co-pay;   a deductibles model comprising a plurality of calculations that determine an impact of deductibles both with and without a change to out of pocket cost and co-pay;   a patient safety program model comprising a plurality of calculations that determine an estimated financial impact of implementing a patient safety program for the prescription drug plan;   a benefit cap model comprising a plurality of calculations that determine an impact of a benefit cap for the prescription drug plan; and   a retail access density model comprising a plurality of calculations that determine a member impact of removing at least one chain prescription drug retailer from the prescription drug plan.   
     
     
         6 . The system of  claim 4 , wherein the clinical model comprises at least one of:
 a dose optimization model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing dose optimization rules;   a quantity per dispensing event model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing quantity per dispensing event rules;   a smart rules model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing smart coverage authorization rules;   a traditional prior authorization model comprising a plurality of calculations that determine an estimated financial impact and an estimated member impact of implementing traditional prior authorization rules; and   a new drug events model comprising a plurality of calculations that determine an estimated impact of a status change for a particular drug, the status change comprising at least one of an expiration of a patent for the drug, a new indication for the drug, a shift of the drug from prescription to over-the-counter, an introduction of the drug to the marketplace, and a withdrawal of the drug from the marketplace.