Systems and methods for routing prescription drug claims between a pharmacy and pharmacy benefit managers

Abstract

Systems and methods for routing prescription drug claims between a pharmacy and a plurality of pharmacy benefit managers (PBMs). The systems and methods implemented by one or more processing circuits. One method includes receiving a prescription drug claim from the pharmacy, the prescription drug claim comprising routing information that causes the pharmacy to send the prescription drug claim to the prescription drug claim routing system. The method further includes obtaining a set of rules for routing the prescription drug claim. The method further includes selecting a PBM from the plurality of PBMs by applying the set of rules to the prescription drug claim. The method further includes modifying the routing information of the prescription drug claim to include updated routing information corresponding to the selected PBM and sending the prescription drug claim to the selected PBM for processing in accordance with the updated routing information.

What is claimed is: 
     
         1 . A prescription drug claim routing system for routing prescription drug claims between a pharmacy and a plurality of pharmacy benefit managers (PBMs), the system comprising:
 one or more processing circuits comprising one or more processors and memory storing instructions that, when executed by the one or more processors, cause the one or more processors to perform operations comprising:
 receiving a prescription drug claim from the pharmacy, the prescription drug claim comprising routing information that causes the pharmacy to send the prescription drug claim to the prescription drug claim routing system; 
 obtaining a set of rules for routing the prescription drug claim; 
 selecting a PBM from the plurality of PBMs by applying the set of rules to the prescription drug claim; 
 modifying the routing information of the prescription drug claim to include updated routing information corresponding to the selected PBM; and 
 sending the prescription drug claim to the selected PBM for processing in accordance with the updated routing information. 
   
     
     
         2 . The prescription drug claim routing system of  claim 1 , the operations further comprising:
 receiving a claim response from the selected PBM responsive to sending the prescription drug claim to the selected PBM for processing;   modifying the claim response from the selected PBM to include information identifying the selected PBM; and   sending the modified claim response to the pharmacy.   
     
     
         3 . The prescription drug claim routing system of  claim 1 , wherein:
 obtaining the set of rules comprises using one or more attributes of the prescription drug claim to select one or more rules applicable to the prescription drug claim; and   the one or more rules applicable to the prescription drug claim define one or more criteria for selecting the PBM from the plurality of PBMs.   
     
     
         4 . The prescription drug claim routing system of  claim 1 , wherein:
 the selected PBM provides multiple different prescription plans; and   selecting the PBM comprises selecting a prescription plan from the multiple different prescription plans provided by the selected PBM by applying the set of rules to the multiple different prescription plans.   
     
     
         5 . The prescription drug claim routing system of  claim 1 , wherein selecting the PBM from the plurality of PBMs comprises:
 using one or more attributes of the prescription drug claim to identify an insurance plan applicable to the prescription drug claim; and   applying the set of rules to the insurance plan and one or more alternative prescription plans applicable to the prescription drug claim.   
     
     
         6 . The prescription drug claim routing system of  claim 1 , wherein:
 the set of rules defines a set of available prescription plan options for processing the prescription drug claim, each of the available prescription plan options corresponding to a PBM of the plurality of PBMs; and   selecting the PBM from the plurality of PBMs comprises evaluating the set of available prescription plan options according to the set of rules to select a prescription plan from the set of available prescription plan options.   
     
     
         7 . The prescription drug claim routing system of  claim 6 , the operations further comprising:
 sending the prescription drug claim to each PBM of the plurality of PBMs corresponding to the available prescription plan options; and   receiving claim responses from the plurality of PBMs corresponding to the available prescription plan options responsive to the prescription drug claim;   wherein evaluating the set of available prescription plan options comprises evaluating the claim responses received the plurality of PBMs corresponding to the available prescription plan options according to the set of rules.   
     
     
         8 . A method for routing prescription drug claims between a pharmacy and a plurality of pharmacy benefit managers (PBMs), the method comprising:
 receiving a prescription drug claim from the pharmacy at a prescription drug claim routing system, the prescription drug claim comprising routing information that causes the pharmacy to send the prescription drug claim to the prescription drug claim routing system;   obtaining a set of rules for routing the prescription drug claim;   selecting a PBM from the plurality of PBMs by applying the set of rules to the prescription drug claim;   modifying the routing information of the prescription drug claim to include updated routing information corresponding to the selected PBM; and   sending the prescription drug claim to the selected PBM for processing in accordance with the updated routing information.   
     
     
         9 . The method of  claim 8 , further comprising:
 receiving a claim response from the selected PBM responsive to sending the prescription drug claim to the selected PBM for processing;   modifying the claim response from the selected PBM to include information identifying the selected PBM; and   sending the modified claim response to the pharmacy.   
     
     
         10 . The method of  claim 8 , wherein:
 obtaining the set of rules comprises using one or more attributes of the prescription drug claim to select one or more rules applicable to the prescription drug claim; and   the one or more rules applicable to the prescription drug claim define one or more criteria for selecting the PBM from the plurality of PBMs.   
     
     
         11 . The method of  claim 8 , wherein:
 the selected PBM provides multiple different prescription plans; and   selecting the PBM comprises selecting a prescription plan from the multiple different prescription plans provided by the selected PBM by applying the set of rules to the multiple different prescription plans.   
     
     
         12 . The method of  claim 8 , wherein selecting the PBM from the plurality of PBMs comprises:
 using one or more attributes of the prescription drug claim to identify an insurance plan applicable to the prescription drug claim; and   applying the set of rules to the insurance plan and one or more alternative prescription plans applicable to the prescription drug claim.   
     
     
         13 . The method of  claim 8 , wherein:
 the set of rules defines a set of available prescription plan options for processing the prescription drug claim, each of the available prescription plan options corresponding to a PBM of the plurality of PBMs; and   selecting the PBM from the plurality of PBMs comprises evaluating the set of available prescription plan options according to the set of rules to select a prescription plan from the set of available prescription plan options.   
     
     
         14 . The method of  claim 13 , the operations further comprising:
 sending the prescription drug claim to each PBM of the plurality of PBMs corresponding to the available prescription plan options; and   receiving claim responses from the plurality of PBMs corresponding to the available prescription plan options responsive to the prescription drug claim;   wherein evaluating the set of available prescription plan options comprises evaluating the claim responses received the plurality of PBMs corresponding to the available prescription plan options according to the set of rules.   
     
     
         15 . A prescription drug claim routing system for routing prescription drug claims between a pharmacy and a plurality of pharmacy benefit managers (PBMs), the system comprising:
 one or more processing circuits comprising one or more processors and memory storing instructions that, when executed by the one or more processors, cause the one or more processors to perform operations comprising:
 receiving a prescription drug claim generated by the pharmacy; 
 obtaining a set of rules for routing the prescription drug claim; 
 selecting a PBM from the plurality of PBMs by applying the set of rules to the prescription drug claim; 
 modifying the prescription drug claim to include routing information corresponding to the selected PBM; and 
 sending the prescription drug claim to the selected PBM for processing in accordance with the routing information. 
   
     
     
         16 . The prescription drug claim routing system of  claim 15 , the operations further comprising:
 receiving a claim response from the selected PBM responsive to sending the prescription drug claim to the selected PBM for processing; and   modifying the claim response from the selected PBM to include information identifying the selected PBM.   
     
     
         17 . The prescription drug claim routing system of  claim 15 , wherein:
 obtaining the set of rules comprises using one or more attributes of the prescription drug claim to select one or more rules applicable to the prescription drug claim; and   the one or more rules applicable to the prescription drug claim define one or more criteria for selecting the PBM from the plurality of PBMs.   
     
     
         18 . The prescription drug claim routing system of  claim 15 , wherein:
 the selected PBM provides multiple different prescription plans; and   selecting the PBM comprises selecting a prescription plan from the multiple different prescription plans provided by the selected PBM by applying the set of rules to the multiple different prescription plans.   
     
     
         19 . The prescription drug claim routing system of  claim 15 , wherein selecting the PBM from the plurality of PBMs comprises:
 using one or more attributes of the prescription drug claim to identify an insurance plan applicable to the prescription drug claim; and   applying the set of rules to the insurance plan and one or more alternative prescription plans applicable to the prescription drug claim.   
     
     
         20 . The prescription drug claim routing system of  claim 15 , wherein:
 the set of rules defines a set of available prescription plan options for processing the prescription drug claim, each of the available prescription plan options corresponding to a PBM of the plurality of PBMs; and   selecting the PBM from the plurality of PBMs comprises evaluating the set of available prescription plan options according to the set of rules to select a prescription plan from the set of available prescription plan options.