Patent Application
20160358289
None.
Many health benefit plan providers offer their plan members the option of obtaining their prescription drugs by mail. For members with chronic conditions or other conditions that require maintenance drugs, a mail order prescription program is an attractive benefit because it is more convenient for members and typically less expensive than obtaining prescription drugs at a neighborhood pharmacy. For many drugs, members have the option of purchasing a drug fill in a 60-day or even a 90-day supply at a lower cost than a 30-day supply.
Although plan members as well as health benefit plan providers benefit from the convenience and lower cost of mail order prescription programs, members are often unaware of the mail order option. Even if they are aware of the option, they may be uncertain about what they need to do to take advantage of the program or which prescriptions they can obtain by mail. Some health benefit plan providers review member pharmacy claim data to identify members with prescription needs that may be fulfilled through a mail order pharmacy. Although review of pharmacy claim data is an effective way to identify candidates for a mail order pharmacy program, members are not notified of the option until after an initial fill for the prescription has been processed and a claim for the fill has been submitted to health plan provider. To take advantage of the mail order option, the member must “switch” the prescription from a current fulfillment option to a mail order option. “Switching” the prescription may require contacting the prescribing physician for authorization to refill the prescription from another source. If the physician provides authorization for refills directly to the member's dispensing pharmacy, “switching” may require providing the physician with new contact information to authorize dispensing of additional fills from the mail order pharmacy.
Some health benefit plan providers offer members a web-based “self-serve” option for enrolling in a mail order pharmacy program and “switching” prescriptions. Members may access a web portal that supports enrollment in a mail order pharmacy program. Typically, the member's pharmacy claim data is automatically reviewed to identify one or more prescriptions that may be fulfilled by mail. The member's prescriptions are identified in a list and the member is provided with a mail order option if the prescription can be filled by mail. The member may be prompted for additional data needed to complete the switch to the mail order option such as a mailing address and payment information as well as prescribing physician contact data.
The health benefits plan provider may also offer enrollment services through a live assistance customer service center. Contact may be initiated by the member or by associates at the center that have access to member data including the member's telephone number. For members with mail order eligible prescriptions, associates at the center may call the member to discuss the mail order option and facilitate the member's switch to mail order using a web-based system that is similar to the “self-serve” system. An associate requests data from the member, enters it in the web-based system, and completes arrangements for the switch such as contacting the prescribing physician to authorize additional fills from the new source.
Although health benefit plan members as well as health benefit plan providers benefit from members “switching” to a mail order pharmacy program, additional benefits may be realized by providing members with a mail order option for filling an initial fill of a prescription. If an initial fill of a prescription and subsequent fills of the prescription are processed through a mail order pharmacy program, the member can take advantage of the convenience and cost savings from the beginning and avoid “switching” the prescription. There is a need for a mail order prescription system and method that allows a member to enter data for a new, previously unfilled prescription. There is a need for a prescription ordering system and method that supports delivery of prescriptions by mail by completing necessary arrangements such as contacting prescribing physicians and obtaining authorization. There is a need for prescription ordering system and method that allows a member to take advantage of the convenience and cost savings of a mail order pharmacy program for new prescriptions.
The present disclosure is directed to a mail order prescription system and method. The mail order prescription system and method supports enrollment and management of health benefit plan members in a mail order pharmacy program. The mail order prescription system and method supports previously filled prescriptions and allows members to enter data for a new, previously unfilled prescriptions. The prescription ordering system and method supports delivery of prescriptions by mail by completing necessary arrangements such as contacting prescribing physicians and obtaining authorization. The disclosed prescription ordering system and method allows a member to take advantage of the convenience and cost savings of a mail order pharmacy program for new prescriptions as well as prescriptions previously filled through other sources.
In an example embodiment, a mail order prescription program is supported by a web portal that allows a user to “switch” current prescriptions and to enter data for new prescriptions. In a self-serve version of the portal, members can review current prescription data and switch eligible prescriptions to a mail order pharmacy program. Members can also add new prescriptions to be fulfilled through the mail order pharmacy program. The member is prompted for data needed for physician authorization to fill the prescription by mail. Another version of the portal may be accessible to associates of the health benefits plan provider that assist members with managing one or more prescriptions that may be filled by mail. If the member has a new prescription, the associate can add the member's new prescription to be fulfilled through the mail order pharmacy. The associated is prompted for data needed for physician authorization to fill the prescription by mail.
In an example embodiment, a Therapeutic Interchange Program (TIP) feature provides additional benefits to members by increasing the number of lower cost alternatives available to members and allowing members to switch to these lower cost alternatives. Members may realize additional cost savings by selecting a generic equivalent or a generic alternative instead of an original prescription. If one or more generic equivalents or alternatives are available for a prescription in the member's list, the member is notified of the other options. The mail order prescription system and method supports the selection of a generic equivalent or a generic alternative by facilitating physician authorization for the selected option.
In an example embodiment of a mail order prescription program available from a health benefits plan provider, members or associates of the provider access a web portal to manage one or more member prescriptions that are filled by mail. The health benefits plan provider may maintain one or more databases comprising drug data for drugs available through the mail order pharmacy program. The health benefits plan provider may further maintain one or more databases comprising member pharmacy claim data for drugs that have been prescribed for the member. Each member's pharmacy claim data may be reviewed to identify prescriptions that could be filled through the mail order pharmacy program. Eligible prescriptions are identified with a target drug list for the mail order pharmacy that is used to filter against pharmacy claims data for prescriptions filled at retail pharmacies. Drugs from the target list that are found in the claims data are flagged as prescriptions that may be moved.
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In an example embodiment, the fax data for the prescribing physician is used to facilitate obtaining authorization for dispensing the prescription from the mail order pharmacy. The fax and prescription data may be used in an automated process for generating and sending authorization fax messages to the prescribing physicians. Once the prescribing physician's authorization is received, fills for the prescribed drug may be processed through the mail order pharmacy.
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In an example embodiment, a “retail-to-mail” application sends the information that is included in the order (i.e., prescriptions, provider contact data, member information, etc.) to a pharmacy management system that sends the prescription and provider data to an automated faxing system. Faxes to prescribing physicians are transmitted using an automated outbound fax system such as one offered by FairFax Imaging, Inc. In an example embodiment, fax forms for mail order pharmacy requests are auto-populated using an XML process. In an example embodiment, the following are fields are populated:
After the fax form is populated with required data and a unique Mail Order Pharmacy Request Number, a cover letter may be added to the form that indicates the attempt number of the request (e.g., first request, second request, third request, final request). The cover letter and form are then transmitted to the prescribing physician. The document may be transmitted using an automated outbound fax system and the fax number from the request. The system follows a fax outreach timeline established by the physician.
Automated fax requests may be logged and tracked according to the Mail Order Pharmacy Request Number as indicated in the XML file. When a fax is received at the prescribing physician's facility, the request may be closed out in a backend system so that no further communications are sent to the member or to the physician. In addition, the unique request number identifies where the request originated. The XML file may identify a department of the health benefits plan provider. The request originator may be one of the following:
The tracking system may have functionality such as the following. If the prescribing physician responds by fax, a fax back image may be attached to the original fax. In addition, exceptions to the original outbound request may be attached. If a fax back is matched to an original fax back template, a validation process may be executed. In addition, the tracking system may interpret the status of a fax (e.g., a received fax, an undeliverable fax, and a bad fax number). If the fax is received by the prescribing physician, the outbound fax system updates a corresponding backend system.
In the event the outbound fax system is unable to deliver the fax to the provided fax number, the system follows a busy/bad number procedure. If an outbound fax fails, the outbound fax system may update the status and resubmit the request. If the outbound fax system receives a busy signal, it continues to try and successfully send the fax to the physician. For example, it may make three attempts based on a configurable interval. If the outbound fax system is able to deliver the fax after the busy signal, it reports the result to the backend system with the fax receipt/status. If the outbound fax system cannot successfully deliver the fax during the allotted attempts, it follows undeliverable fax procedure.
If the delivery of a fax to a provider is undeliverable, the outbound fax system updates the backend system with an undeliverable status receipt and places the request in an appropriate failed fax queue for an associate to research and confirm the fax number. After the associate confirms the correct fax number, the associate updates the fax number, places the fax back into the backend system, and the system follows the original auto fax send process.
If the system determines that the number provided is a bad fax number (e.g., a normal phone number), the system updates the backend system and places the request in an appropriate failed fax queue for an associate to research and confirm the fax number. After the associate confirms the correct fax number, the associate updates the fax number, places the fax back into the backend system, and the system follows the original auto fax send process.
When a mail order pharmacy fax is received by the prescribing physician, the fax includes a barcode that includes all information from the XML file. The system can read the inquiry number/barcode and determine that the fax is a mail order pharmacy request and the department where the request originated. After the system has determined that the request is a mail order pharmacy fax, the system appropriately closes out the request and forwards information onto an item entry within other systems.
Once the request is sent from the automated faxing system to the pharmacy management system, it is reviewed for accuracy and approval. Once the review is complete, an order is created and then moved for review by a pharmacist before filling. Following pharmacist review, the order is filled and packaged for shipping.
While certain embodiments of the disclosed mail order prescription system and method are described in detail above, the scope of the invention is not to be considered limited by such disclosure, and modifications are possible without departing from the spirit of the invention as evidenced by the claims. For example, elements of the user interface and page layouts may be varied and fall within the scope of the claimed invention. Various aspects of user interactions and presentation of data may be varied and fall within the scope of the claimed invention. One skilled in the art would recognize that such modifications are possible without departing from the scope of the claimed invention.
