Methods and systems for maintaining pharmacy provider networks

Abstract

Methods and systems for maintaining pharmacy provider networks are described. In one embodiment, claims adjudication data associated with a member and a prescribed drug is accessed. The prescribed drug associated with the member is classified as one of an acute medication and a maintenance medication. A pharmacy provider network is associated with the prescribed drug based on, at least in part, classifying the prescribed drug. It is determined if a pharmacy associated with the claims adjudication data is included within the pharmacy provider network associated with the prescribed drug. A pharmacy claim may be adjudicated for the prescribed drug based on the claim and the pharmacy provider network. Additional methods and systems are disclosed.

What is claimed is: 
     
         1 . A method for communicating over a network to fill a prescription comprising:
 retrieving claims adjudication data associated with a member and a prescribed drug stored in the memory;   determining, on a processor, whether a number of available fills of the prescribed drug exceeds an acute medication threshold number of available fills, wherein the acute medication threshold number is stored in a database and set in a pharmacy benefit provided to the member;   classifying, using the processor, the prescribed drug associated with the member as one of an acute medication and a maintenance medication based on the determination of whether the number of available fills of the prescribed drug exceeded the acute medication threshold number of available fills;   associating, on the processor, the prescribed drug with a type of pharmacy provider network based on classification of the prescribed drug, the type of pharmacy provider network being divided into two distinct subsets of an acute medication pharmacy provider network or a maintenance medication pharmacy provider network for the acute medication and the maintenance medication, respectively;   determining, on the processor, whether a pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network associated with the prescribed drug;   adjudicating, on the processor, a pharmacy claim for the prescribed drug through the pharmacy based on the pharmacy claim, the adjudication data and a determination of whether the pharmacy is included within the type of pharmacy provider network; and   filling the prescription at the pharmacy after receipt of the adjudication response.   
     
     
         2 . The method of  claim 1 , wherein retrieving the claims adjudication data includes receiving an adjudication request from a pharmacy relative to the prescribed drug for the member. 
     
     
         3 . The method of  claim 1 , wherein retrieving the claims adjudication data includes accessing historical claims adjudication data for the member. 
     
     
         4 . The method of  claim 1 , wherein classifying the prescribed drug comprises: analyzing the claims adjudication data to determine one or more of a drug attribute and a fill attribute associated with the prescribed drug. 
     
     
         5 . The method of  claim 1 , wherein classifying the prescribed drug comprises: identifying one of a drug identity, a drug type, and a drug category. 
     
     
         6 . The method of  claim 1 , wherein classifying the prescribed drug comprises: determining that a number of fill requests of the prescribed drug exceeds an acute medication threshold number of fill requests. 
     
     
         7 . The method of  claim 1 , further comprising:
 associating a first set member benefits with the prescribed drug for the acute medication pharmacy provider network; and   associating a second set of member benefits with the prescribed drug for the maintenance medication pharmacy provider network.   
     
     
         8 . The method of  claim 1 , wherein accessing the claims adjudication data includes accessing historical claims adjudication data for the member. 
     
     
         9 . A non-transitory machine-readable medium storing instructions for filling a prescription over a network, which, when executed by one or more processors, cause the one or more processors to:
 selecting a variable number for an acute medication threshold number of available fills for each drug available in the network;   access claims adjudication data associated with a member and a prescribed drug; determine whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills using the claims adjudication data;   classify the prescribed drug associated with the member as one of an acute medication and a maintenance medication based on the determination of whether the number of available fills of the prescribed drug exceeded the acute medication threshold number of available fills;   associate the prescribed drug with a type of pharmacy provider network based on classification of the prescribed drug, the type of pharmacy provider network being an acute medication pharmacy provider network or a maintenance medication pharmacy provider network;   determine whether a pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network associated with the prescribed drug; and   authorize a filling of the prescription for the member at the pharmacy after determining whether the pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network to execute a physical filling of the prescription for the member at the pharmacy.   
     
     
         10 . The non-transitory machine-readable medium of  claim 9 , wherein the instruction to access the claims adjudication data includes receiving an adjudication request from a pharmacy relative to the prescribed drug for the member. 
     
     
         11 . The non-transitory machine-readable medium of  claim 9 , wherein the instruction to classify the prescribed drug comprises:
 analyzing the claims adjudication data to determine one or more of a drug attribute and a fill attribute associated with the prescribed drug.   
     
     
         12 . The non-transitory machine-readable medium of  claim 9 , wherein the instruction to classify the prescribed drug comprises:
 identifying one of a drug identity, a drug type, and a drug category.   
     
     
         13 . The non-transitory machine-readable medium of  claim 9 , wherein the instruction to classify the prescribed drug comprises:
 determining that a number of fill requests of the prescribed drug exceeds an acute medication threshold number of fill requests.   
     
     
         14 . The non-transitory machine-readable medium of  claim 9 , wherein the instructions, when executed by the one or more processors, further cause the one or more processors to:
 associate a first set member benefits with the prescribed drug for the acute medication pharmacy provider network; and   associate a second set of member benefits with the prescribed drug for the maintenance medication pharmacy provider network.   
     
     
         15 . A method for filling a prescription comprising:
 receiving, on a processor, a pharmacy claim to adjudicate the pharmacy claim associated with a member and a prescribed drug;   selecting an acute medication threshold number of available fills, which is a selectable variable;   transmitting the acute medication threshold number of available fills to the processor;   classifying, on the processor, the prescribed drug associated with the member as a maintenance medication based on a determination of whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills;   determining, on the processor, that a pharmacy associated with a request to adjudicate the pharmacy claim is included within an acute medication pharmacy provider network; and   transmitting, on the processor, a warning that a modified set of member benefits are associated with filling the prescribed drug at the pharmacy based on classification of the prescribed drug as a maintenance medication and a determination that the pharmacy is included within the acute medication pharmacy provider network; and   authorizing a filling of the prescription for the member at the pharmacy after receipt of an adjudication response associated with the member.   
     
     
         16 . The method of  claim 15 , wherein the modified set of member benefits include an elevated member co-pay. 
     
     
         17 . The method of  claim 16 , wherein determining includes transitioning the prescription from the acute medication pharmacy provider network and a maintenance medication pharmacy provider network when the acute medication threshold number is exceeded and filling the prescription using the maintenance medication pharmacy provider network with a different member benefit than a member benefit at the acute medication pharmacy provider network. 
     
     
         18 . The method of  claim 11 , further comprising filling the prescription at the pharmacy after receipt of the adjudication response.