Prescription drug prior authorization system and method

Abstract

An online application for approving prior authorization requests for prescription drugs. The application is used by pharmacy benefits providers, physicians, and pharmacies to request prior authorizations for drugs and to receive approvals automatically if a requested drug meets authorization criteria. The online application is accessible through a group pharmacy benefits provider portal on a web site. Requests are processed through a pharmacy benefits manager computer that determines whether prior authorization is required and through a pharmacy benefits provider computer when the pharmacy benefits manager computer determines that prior authorization is required. Requests that meet certain authorization criteria are approved automatically. Requests that cannot be approved automatically are submitted for review by a clinical pharmacy review division that access requests through a drug request transaction computer.

1 . A computerized method for receiving and processing electronic prior authorization drug requests comprising:
 (a) receiving at a server an electronic prior authorization drug request, said request comprising:
 (1) identifying information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member; and 
 (2) identifying information for a prescribing physician submitting said electronic prior authorization drug request for said member; 
   (b) assigning by said server a reference identifier to said electronic prior authorization drug request;   (c) logging by said server said electronic prior authorization drug request with said reference identifier in a drug request transaction computer;   (d) at said drug request transaction computer, automatically applying electronic authorization criteria to said electronic prior authorization drug request to automatically select a prior authorization decision for dispensing of said drug to said member; and   (e) automatically updating said electronic prior authorization drug request in said drug request transaction computer according to said automatically selected prior authorization decision.   
     
     
         2 . The computerized method of  claim 1  wherein said identifying information for said drug prescribed to said member comprises a drug identifier, a quantity, a quantity per days value, and a number of refills. 
     
     
         3 . The computerized method of  claim 1  wherein said prior authorization decision is selected from the group consisting of:
 approved and denied. 
 
     
     
         4 . The computerized method of  claim 3  wherein said approved prior authorization decision is selected from the group consisting of:
 approved for a specified period of time and approved indefinitely. 
 
     
     
         5 . The computerized method of  claim 4  further comprising providing a clinical pharmacy representative with access to said electronic prior authorization request if said prior authorization decision is denied. 
     
     
         6 . The computerized method of  claim 5  wherein said prior authorization decision is updated to approved in said drug request transaction computer if said clinical pharmacy representative determines authorization criteria for said request is met. 
     
     
         7 . The computerized method of  claim 1  further comprising transmitting said prior authorization decision to a pharmacy benefits manager. 
     
     
         8 . The computerized method of  claim 7  further comprising:
 (f) receiving at said pharmacy benefits manager from a pharmacy computer system a drug request for said drug, said drug request comprising said identifying information for said member; 
 (g) locating at said pharmacy benefits manager said prior authorization decision applicable to said drug; and 
 (h) transmitting to said pharmacy computer system said prior authorization decision applicable to said drug. 
 
     
     
         9 . A computerized system for receiving and processing electronic prior authorization drug requests comprising:
 a server executing instructions to:   (a) receive at said server an electronic prior authorization drug request, said request comprising:
 (1) identifying information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member; and 
 (2) identifying information for a prescribing physician submitting said electronic prior authorization drug request for said member; 
   (b) assign by said server a reference identifier to said electronic prior authorization drug request;   a drug request transaction computer executing instructions to:   (a) log by said drug request transaction computer said electronic prior authorization drug request with said reference identifier;   (b) automatically apply by said drug request transaction computer electronic authorization criteria to said electronic prior authorization drug request to automatically select a prior authorization decision for dispensing of said drug to said member; and   (c) automatically update by said drug request transaction computer said electronic prior authorization drug request according to said automatically selected prior authorization decision.   
     
     
         10 . The computerized system of  claim 9  wherein said identifying information for said drug prescribed to said member comprises a drug identifier, a quantity, a quantity per days value, and a number of refills. 
     
     
         11 . The computerized system of  claim 9  wherein said prior authorization decision is selected from the group consisting of:
 approved and denied. 
 
     
     
         12 . The computerized system of  claim 11  wherein said approved prior authorization decision is selected from the group consisting of:
 approved for a specified period of time and approved indefinitely. 
 
     
     
         13 . The computerized system of  claim 9  further comprising a clinical pharmacy computer for providing a representative with access to said electronic prior authorization request if said prior authorization decision is denied. 
     
     
         14 . The computerized system of  claim 13  wherein said prior authorization decision is updated to approved in said drug request transaction computer if said clinical pharmacy representative determines authorization criteria for said request is met. 
     
     
         15 . The computerized system of  claim 9  further comprising a pharmacy benefits manager computer for receiving said prior authorization decision. 
     
     
         16 . The computerized system of  claim 15  wherein said pharmacy benefits manager further executes instructions to:
 (a) receive at said pharmacy benefits manager from a pharmacy computer system a drug request for said drug, said drug request comprising said identifying information for said member; 
 (b) locate at said pharmacy benefits manager a prior authorization decision applicable to said drug; and 
 (c) transmit to said pharmacy computer system said prior authorization decision applicable to said drug. 
 
     
     
         17 . A computerized method for receiving and processing electronic prior authorization drug requests comprising:
 (a) receiving at a server from a physician computerized device an electronic prior authorization drug request, said request comprising:
 (1) identifying information for a member of a pharmacy benefits plan and identifying information for a drug prescribed to said member; and 
 (2) identifying information for a prescribing physician submitting said electronic prior authorization drug request for said member; 
   (b) logging in a drug request transaction computer said electronic prior authorization drug request with a reference identifier;   (c) at said drug request transaction computer, automatically applying electronic authorization criteria to said electronic prior authorization drug request to automatically select a prior authorization decision for dispensing of said drug to said member;   (d) automatically updating said electronic prior authorization drug request in said drug request transaction computer according to said automatically selected prior authorization decision; and   (e) transmitting to said physician computerized device said prior authorization decision.   
     
     
         18 . The computerized method of  claim 17  wherein said physician computerized device is selected from the group consisting of a handheld device and a personal computer. 
     
     
         19 . The computerized method of  claim 17  wherein said prior authorization decision is selected from the group consisting of:
 approved for a specified period of time, approved indefinitely, and denied. 
 
     
     
         20 . The computerized method of  claim 17  wherein transmitting to said physician computerized device said prior authorization decision comprises transmitting said prior authorization decision after said prior authorization request is reviewed by a clinical pharmacy representative.