US20120173263A1

US20120173263A1 - Methods and systems for implementation of therapy programs

Info

Publication number: US20120173263A1
Application number: US13/337,618
Authority: US
Inventors: Robert F. Nease, JR.; Katherine Harini Sundararaman; Mark Alan Engel; Kevin C. Cohan
Original assignee: Express Scripts Inc
Current assignee: Express Scripts Inc
Priority date: 2011-01-03
Filing date: 2011-12-27
Publication date: 2012-07-05
Also published as: US20120173298A1; US8682704B2

Abstract

Methods and systems for implementation of therapy programs are described. In one embodiment, it is determined that a member is enrolled in a drug benefit program. It is determined that a decision deadline has occurred for continuing an aspect of a benefit of the drug benefit program. It is determined that a decision response has not been received from the member. A suspension of the aspect of the benefit of the drug benefit program is generated based on the determination that the decision response has not been received from the member. Other methods and systems are described.

Description

CROSS-REFERENCE TO A RELATED APPLICATION

The present application claims the benefit of U.S. provisional patent application Ser. No. 61/429,405, entitled “Methods and Systems for Promoting and Increasing Participation in Healthcare Related Events and Programs” filed on 3 Jan. 2011, the entire disclosure of which is incorporated herein by reference.

FIELD

The field relates to therapy programs, and more particularly to implementation of therapy programs.

BACKGROUND

Pharmacy benefit managers offer different benefit programs that may allow members of a health plan to receive particular services and/or savings. The suitability of the benefit programs may vary depending upon the needs and circumstances of the various members. Often participation in various benefit programs is underutilized due to a lack of knowledge of the benefit programs by the members of the health plan. Under some health plans, participation in benefit programs, or specific coverage plans, may be mandated by a sponsor of the health plan. Such mandated participation may often be met with resistance by members participating in the health plan.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a block diagram of an example system, according to an example embodiment;

FIG. 2 is a block diagram of an example user device that may be deployed within the system of FIG. 1, according to an example embodiment;

FIG. 3 is a block diagram of an example program manager device that may be deployed within the system of FIG. 1, according to an example embodiment;

FIG. 4 is a block diagram of an example active choice subsystem that may be deployed within the user device of FIG. 2 or the program manager device of FIG. 3, according to an example embodiment;

FIGS. 5-6 are process flows illustrating methods for promoting therapy implementation programs, according to an example embodiment;

FIGS. 7-11 are example timelines and process flows associated with example therapy implementation programs; and

FIG. 12 is a block diagram of a machine in the example form of a computer system within which a set of instructions for causing the machine to perform any one or more of the methodologies discussed herein may be executed or stored.

DETAILED DESCRIPTION

Example methods and systems for implementation of therapy programs are described. In the following description, for purposes of explanation, numerous specific details are set forth in order to provide a thorough understanding of example embodiments. It will be evident, however, to one of ordinary skill in the art that embodiments of the invention may be practiced without these specific details.
Generally, when individuals are effectively forced to make a decision regarding participation in healthcare related programs, they may participate at a greater rate than if participation is simply offered as an option or an alternative. The systems and methods may, in some embodiments, promote healthcare related programs and increase participation in healthcare related programs by requiring members to make an active decision regarding participation in a therapy implementation program, as part of a healthcare related program, while providing an alternative to mandatory participation in the therapy implementation programs. Participation in therapy implementation programs may be encouraged through the use of general communications informing members of the therapy implementation programs, and targeted notifications to individual members that have been identified as being eligible candidates for one, or more than one, specific therapy implementation programs. Members identified as being eligible candidates for a therapy implementation program may be required to choose whether or not they wish to participate in the therapy implementation program. In some embodiments, if the member does not make a choice, an aspect of a benefit of a healthcare related program in which the member is enrolled may be altered. For example, the member may be automatically enrolled in the program and/or may be subject to an intervention regarding participation in the therapy implementation program.
Pharmacy benefit managers (PBMs) and health plan managers may offer benefit programs to members of pharmacy benefit plans or medical plans. In various embodiments, therapy implementation programs may encourage members to select a pharmacy, or pharmacy network, that offers reduced rates for participation, encourage the use of services of a specialty pharmacy for appropriate members, encourage participation in a step therapy program, encourage the use of generic substitutes for prescribed brand name drugs, encourage the use of home delivery pharmacies, encourage the use of specific sets of drugs of treatment, and/or encourage the use of programs that may improve adherence to a prescribed treatment regimen.
FIG. 1 is a block diagram of an example system 100, according to an example embodiment. The system 100 is an example embodiment in which participation in a therapy implementation program may be promoted. The system 100 includes a user device 102 in communication with a program manager device 106 over a network 104.
The user device 102 is used by a device operator. The device operator may be a member of a pharmacy benefit plan, and may use the user device to make participation choices for therapy implementation programs. The user device 102 may be a stand-alone device that solely provides at least some of the functionality to enable choices of therapy implementation program participation, or may be a multi-use device that has functionality outside of choosing participation in therapy implementation programs as described herein. Examples of the user device 102 include a set-top box (STB), a receiver card, a mobile telephone, a personal digital assistant (PDA), a display device, a portable gaming unit, and a computing system; however other devices may also be used. In some embodiments, the user device 102 may include a computing system. For example, the user device 102 may include a mobile electronic device, such an IPHONE or IPAD device by Apple, Inc., mobile electronic devices powered by ANDROID by Google, Inc., and a BLACKBERRY device by Research In Motion Limited. The user device 102 may also include other computing devices, such as desktop computing devices, notebook computing devices, netbook computing devices, gaming devices, and the like. Other types of electronic devices may also be used.
The network 104 by which the user device 102 communicates with the program manager device 106 may include, by way of example, Mobile Communications (GSM) network, a code division multiple access (CDMA) network, 3rd Generation Partnership Project (3GPP), an Internet Protocol (IP) network, a Wireless Application Protocol (WAP) network, a WiFi network, or an IEEE 802.11 standards network, as well as various combinations thereof. Network 104 may also include optical communications. Other conventional and/or later developed wired and wireless networks may also be used.
The program manager device 106 is a device, or more than one device, operated by an entity at least partially responsible for the creation and/or management of therapy implementation programs. While the program manager operating the program manager device 106 is typically a pharmacy benefit manager (PBM), other entities may operate the program manager device 106 either on behalf of themselves, the PBM, or another entity.
In general, a client engages a PBM to offer a drug benefit program. Examples of clients include governmental organizations (e.g., Federal government agencies, the Department of Defense, the Centers for Medicare and Medicaid Services and state government agencies), middle market companies, large national employers, health insurance companies that have carved out the drug benefit, and the like. A person who is a participant or member of a drug benefit program offered by the client may obtain prescription drugs according to pricing, pharmacy selection, rebates, discounts and the like provided by the terms of the drug benefit program. The PBM may offer various therapy implementation programs that may impact the pricing, pharmacy selection, rebased, discounts, and the like, provided to members of the drug benefit plan.
The client's offered drug benefit program may be a stand-alone drug benefit operated by the PBM, or as part of a health care benefit operated by a health insurance company where the PBM services are offered directly by the health insurance company or offered indirectly by the PBM on behalf of the health insurance company. In some embodiments, the methods and systems may generally be used to promote participation in therapy implementation programs offered by the PBM.
The program manager device 106 may be in communication directly (e.g., through local storage) and/or through the network 104 (e.g., in a cloud configuration or software as a service) with a database 108. The database 108 may be deployed on the user device 102, the program manager device 106, both the user device 102 and the program manager device 106, partially on the user device 102 and partially on the program manager device 106, on a separate device, or may otherwise be deployed. The database 108 may store member data 110, and/or program data 112.
The member data 110 includes information regarding members of the pharmacy benefit plan. In general, the member data 110 may include member name, member contact information (e.g., address, telephone number, email address, and the like), and member prescription data (e.g., prescribed drugs, prescription history, pharmacy usage, and the like).
The program data 112 may include information regarding one, or more than one, therapy implementation programs offered by the PBM. In general, the program data 112 may include an identification of the therapy implementation programs, eligibility requirements for the therapy implementation programs, terms of the therapy implementation programs, participation information for the therapy implementation programs, and the like. In some embodiments, the program data 112 may include therapy implementation program criterion, such as time periods and/or deadlines for members to execute their choice default enrollment information, and/or intervention information (e.g., criterion for implementing an intervention, what type of intervention may be implemented, and the like).
While the system 100 in FIG. 1 is shown to include single devices 102, 106, multiple devices may be used. The devices 102, 106 may be the same type of device or may be different device types. When multiple devices are present, the multiple devices may be of the same device type or may be a different device type. Moreover, system 100 shows a single network 104, however, multiple networks can be used. The multiple networks may communicate in series with each other to link the devices 102, 106 or in parallel to link the devices 102, 106.
FIG. 2 illustrates the user device 102, according to an example embodiment. The user device 102 may be used by a device operator to make participation choices relative to one, or more than one, therapy implementation programs. The user device 102 may be deployed in the system 100, or may otherwise be used.
The user device 102 may include an active choice subsystem 202. The active choice subsystem 202 may enable the choice to participate in a therapy implementation program. Examples of therapy implementation programs may include programs that allow members to select a pharmacy, or pharmacy network, that offers reduced rates for prescriptions; programs that allow the member to use services of a specialty pharmacy; programs that allow the member to participate in a step therapy program; programs that allow the member to use of generic substitutes for prescribed brand name drugs; programs that allow the member to use home delivery pharmacies; programs that encourage the use of specific sets of drugs of treatment; and/or programs that may improve adherence to a prescribed treatment regimen.
FIG. 3 illustrates the program manager device 106, according to an example embodiment. The program manager device 106 may be deployed in the system 100, or may otherwise be used.
The program manager device 106 may include the active choice subsystem 202. In some embodiments, the active choice subsystem 202, when used, may provide server-side functionality to the user device 102. By way of example, the active choice subsystem 202 may be deployed in both the user device 102 and the program manager device 106. The user device 102 may then perform some of the functionality, while other functionality is performed by the program manager device 106.
FIG. 4 illustrates an example the active choice subsystem 202 that may be deployed in the user device 102, the program manager device 106, or otherwise deployed in another system. One or more modules are communicatively coupled and included in the active choice subsystem 202 to enable therapy implementation program promotion and participation. The modules of the active choice subsystem 202 that may be included are an early phase communication module 402, a member data access module 404, an eligibility module 406, a notification module 408, a benefit alteration module 410, and an intervention module 412.
In some embodiments, the modules of the active choice subsystem 202 may be distributed so that some of the modules are deployed in the user device 102 and some modules are deployed in the program manager device 106. In one embodiment, the modules are deployed in memory and executed by a processor coupled to the memory. The functionality contained within the modules 402-412 may be combined into a lesser number of modules, further divided among a greater number of modules, or redistributed among existing modules. Other configurations including the functionality of the modules 402-412 may be used.
In some embodiments, the early phase communication module 402 may generate an early phase communication regarding one, or more than one, therapy implementation programs. The early phase communication module 402 may also transmit the generated early phase communication to one, or more than one, members of a health care plan, under which the therapy implementation program is offered. The early phase communication may include information about the therapy implementation program, such as requirements for eligibility, benefits provided to members who choose to participate in the program and the like. The early phase communication may include, for example, a mail-based communication (e.g., a letter or a postcard mailed to members), a telephone communication (such as an automated telephone message), an email communication, a facsimile communication, or the like.
In some embodiments, the early phase communication module 402 may generate the early phase communication may be generated, and transmitted to one, or several, members relatively early in the process of promoting the therapy implementation program. For example, the early phase communication may be generated when a new therapy implementation program is offered and/or at a period at or near renewal of the health plan under which the therapy implementation program may be available.
In some embodiments, the member data 110 associated with members of a health plan may be accessed by the member data access module 404. The member data 100 may be accessed by the member data access module 404 from the database 108, from the user device 102, from the program management device 106, or may be otherwise accessed.
In some embodiments, the member data access module 404 may access the member data 110 by receiving data associated with the member. Receiving data associated with the member may include, for example, receiving data associated with the member directly via the user device, 102. In some embodiments, receiving the data associated with the member may include receiving data associated with the member through the network 104 from the user device 102, from the program manager device 106, or from a different device.
In some embodiments, the eligibility module 406 may determine whether a member qualifies and/or is eligible for a therapy implementation program, or for more than one therapy implementation program. For example, different therapy implementation programs may be suited to members having particular needs, members who utilize particular services, and/or members who may otherwise benefit and/or members that may otherwise have a likelihood of participating in a given therapy implementation program. In some embodiments, the eligibility module 406 may determine whether a member qualifies and/or is eligible for a therapy implementation program based on the member data 110 associated with the member. For example, the eligibility module 406 may compare the member data 110 associated with the member to one, or more than one, therapy implementation program criterion associated with the therapy implementation program. In some embodiments, comparing the member data 110 and the therapy implementation program criterion may include accessing the program data 112 from the database 108. The program data 112 may be accessed by the eligibility module 406 via the network 104, for example, from the user device 102, from the program manager device 106, or from another device.
The program data 112 may include one, or more than one, therapy implementation program criterion. The therapy implementation program criterion may include, for example, a decision deadline for receiving a member decision regarding participation in the therapy implementation program, requirements for member eligibility in the therapy implementation program, drug benefit program benefit alterations that may be associated with participation, non-participation, and/or non-decision regarding participation in the therapy implementation program. In some embodiments, the eligibility module 406 may determine a decision deadline applicable to the member based on the program data 112.
In some embodiments, the therapy implementation program may include a prescription drug home delivery program. The prescription drug home delivery program may allow the member to receive prescription drugs via home delivery, for example as opposed to receiving the prescription drugs from a retail pharmacy. In some embodiments, the eligibility module 406 may determine that the member is eligible for the prescription drug home delivery program based on a prescription history associated with the member. For example, the prescription history may indicate that the member is undertaking a relatively long-term treatment (e.g., to treat a condition such as high blood pressure, high cholesterol, etc.) that may include more than one fill of a prescription, and/or fills of prescriptions according to a defined regimen. In some embodiments, the eligibility module 406 may determine that the member is eligible for the prescription drug home delivery program based on an indication in the member data that the member is taking specialty prescription drugs. In some embodiments, the eligibility module 406 may determine that the member is eligible for the prescription drug home delivery program based on a history of lower than desired adherence of the member to a prescribed course of treatment.
In some embodiments, the therapy implementation program may include a value-enhanced pharmacy network program. The eligibility module 406 may determine that the member is eligible for the value-enhanced pharmacy network program based on, for example, the member's current non-participation in the value-enhanced pharmacy network program.
In some embodiments, the therapy implementation program may include a prescription drug selection program. The eligibility module 406 may determine that the member is eligible for the prescription drug selection program based on an indication in the member data 110 that the member is taking a non-formulary prescription drug, or that the member is taking a drug included within a step therapy program.
In some embodiments, the notification module 408 may generate a notification to the member based on a determination that the member qualifies for and/or is eligible for a therapy implementation program by the eligibility module 406. In some embodiments, the notification module 408 may generate the notification to the member in response to a determination that a decision deadline for electing to participate, or to not participate in a therapy implementation program is applicable to the member. The notification module 408 may transmit the notification that the member qualifies and/or is eligible for the therapy implementation program to the member. The notification may include, for example, a mail-based communication (e.g., a letter or a postcard mailed to members), a telephone communication (such as an automated telephone message), an email communication, a facsimile communication, or the like.
In some embodiments, the notification generated by the notification module 408 may include a targeted notification. In an example embodiment, the notification may be transmitted to a member who has recently joined a health plan (e.g., the member may be a new employee of a company participating in the health plan and/or otherwise begins to participate in a health plan under which the therapy implementation program is available). In an example embodiment, the notification may be transmitted to a member determined to be a preferred candidate for use of the therapy implementation program (e.g., based on pharmacy usage, prescribed drugs, or the like) based on a determination by the eligibility module 406.
In some embodiments, the notification may indicate that the member may be able to elect to participate in the therapy implementation program, or may decline to participate in the therapy implementation program. In some embodiments, the notification may indicate that, while the member may elect or decline to participate in the therapy implementation program, the member may be required to make a choice. The notification may further include information concerning the benefits and/or advantages of participating in the therapy implementation program. The notification may indicate that if a choice is not received from the member within a specified period of time, one, or more than one benefits under the pharmacy benefit program may be altered, a default election regarding participation in the therapy implementation program may be made, and/or other action by the PBM may occur.
In some embodiments, the benefit alteration module 410 may determine that a decision response has not been received from the member before the occurrence of the decision deadline (e.g., that was determined by the eligibility module 406 based on the program data 112, or otherwise determined). In some embodiments, the benefit alteration module 410 may determine that the decision response has not been received from the member before the occurrence of the decision deadline based on a determination that the decision deadline has occurred for continuing an aspect of a benefit of the drug benefit program. For example, if the member does not respond to the notification generated by the notification module 408, the benefit alteration module 410 may determine that a decision (e.g., enrollment designation for participating or for not participating in the therapy implementation program) has not been received in response to the notification generated by the program notification module 408.
In some embodiments, the benefit alteration module 410 may alter an aspect of a benefit of the drug benefit program based on the determination that the member response has not been received. In some embodiments, the benefit alteration module 410 may generate a suspension of the aspect of the benefit of the drug benefit program based on the determination that the decision response has not been received from the member. The aspect of the benefit of the drug benefit program altered and/or suspended by the benefit alteration module 410 may include, for example, prescription drug delivery channel benefit available to the member for one or more prescription drugs (e.g., such as specialty drugs, drugs associated with a relatively long term treatment regimen, or the like) purchased at a retail pharmacy as opposed to being purchased through a home delivery pharmacy; a pharmacy network selection benefit available to the member for prescription drugs purchased at a pharmacy not included within a value-enhanced pharmacy network; a prescription drug selection benefit for non-formulary drugs, for a back-up drug included within a step-therapy program; or other aspect of a benefit.
In some embodiments, the intervention module 412 may implement an intervention based on the alteration (e.g., by the benefit alteration module 410) of an aspect of a benefit of the drug benefit program. Implementing the intervention may include, for example, enrolling the member in the therapy implementation program (e.g., based on a default enrollment included within the program data 112). For example, in some embodiments, implementing the intervention may include enrolling the member in a value-enhanced pharmacy network program, enrolling the member in a step therapy program, enrolling the member in an adherence improvement program, enrolling the member in a prescription drug home delivery program, or the like.
In some embodiments, the intervention module 412 may receive a prescription refill request by the member, e.g., as a result of the member requesting a refill of a prescription at a retail pharmacy or a home delivery pharmacy (e.g., based on a claim submitted by the pharmacy attendant to the refill request). In some embodiments, the intervention module 412 may implement a pharmacy intervention based on the alteration of the aspect of the benefit of the drug benefit program. The pharmacy intervention may include, for example, a denial of coverage for the prescription under the drug benefit program and/or an increased co-pay required from the member for the prescription refill. In some embodiments, the intervention module 412 may implement the intervention at the first attempted prescription refill after the aspect of the benefit has been altered. In other embodiments, the intervention module 412 may generate a notification regarding the alteration of the aspect of the benefit at the first attempted prescription refill, and may implement the intervention at a later attempted prescription refill if a decision has not been received at the time of the later attempted prescription refill.
In some embodiments, a notification may be generated in response to the implementation of the intervention. The notification may, for example instruct the member that a decision must be made in order for the suspension of the aspect of the benefit to be removed. In some embodiments, the intervention may include permanently altering the aspect of the benefit. In such an embodiment, once the deadline for receiving the decision to participate or to not participate has occurred, the member may be enrolled in the therapy implementation program and may no longer have the ability to choose not to participate.
In an example embodiment, the therapy implementation program may include a prescription drug selection program. For example, the therapy implementation program may require a member to make a decision as to whether to transition from a non-formulary prescription drug to a formulary prescription drug. If a decision is not received from the member regarding participation in the therapy implementation program, a coverage benefit for non-formulary prescription drugs may be suspended. In some embodiments, when the member seeks to fill and/or refill a prescription for a non-formulary drug coverage for the prescription under the drug benefit program may be denied, requiring the member to pay the full retail price for the prescription and/or to pay a higher co-pay. In another example embodiment, the therapy implementation program may require the member to make a decision regarding participation in a step-therapy program. If a decision is not received from the member regarding participation in the therapy implementation program, a coverage benefit for a back-up drug may be suspended. In some embodiments, when the member seeks to fill and/or refill a prescription for a back-up drug, coverage for the prescription under the drug benefit program may be denied, requiring the member to pay the full retail price for the prescription and/or to pay a higher co-pay.
In an example embodiment, the therapy implementation program may include a delivery channel access program, requiring the member to make a decision whether to receive certain prescription drugs via home delivery of the prescription drugs. Example of prescription drugs that may be subject to the delivery channel access program may include, for example, specialty drugs, drugs associated with a relatively long term treatment regimen, and/or drugs associated with a treatment regimen that the member has exhibited an adherence below a desired threshold adherence. In some embodiments, if the member does not make a decision whether to participate in the therapy treatment program, a coverage benefit for retail purchase of the subject prescription drugs may be suspended. In some embodiments, when the member seeks to fill and/or refill a prescription for a drug subject to the delivery channel access program, coverage for the prescription under the drug benefit program may be denied, requiring the member to pay the full retail price for the prescription and/or to pay a higher co-pay.
In an example embodiment, the therapy implementation program may include a pharmacy network selection program. For example, a member may be required to make a decision whether to utilize a value-enhanced pharmacy network. In some embodiments, if the member does not make a decision whether to participate in the therapy treatment program, a coverage benefit for prescription drugs purchased at pharmacies not included within the value-enhanced pharmacy network may be suspended. In some embodiments, when the member seeks to fill and/or refill a prescription at a pharmacy not included within the value-enhanced pharmacy network, coverage for the prescription may be denied, requiring the member to pay the full retail price for the prescription and/or to pay a higher co-pay.
The active choice subsystem 202 may promote therapy implementation programs and participation in therapy implementation programs. In some embodiments, the active choice subsystem 202 may enable members of a drug benefit program to choose to participate in therapy implementation programs or choose not to participate in therapy implementation programs. In some embodiments, the active choice subsystem 202 may require the member to choose to participate in the therapy implementation program or to not participate in the therapy implementation program. In the event that the member does not make a choice to either participate in the therapy implementation program or to not participate in the therapy implementation program the active choice subsystem 202 may alter an aspect of a benefit implement of the drug benefit program and/or may implement an intervention. The intervention may include a default enrollment designation for the therapy implementation program, may include a denial of a request to refill a prescription, may include a requirement of a modified co-payment associated with the refill of a prescription, may include a notification to the member and/or to a pharmacy receiving a request to refill a prescription, or the like.
FIG. 5 illustrates a method 500 for promoting therapy implementation programs and increasing participation in therapy implementation programs, according to an example embodiment. The method 500 may be performed by the user device 102, partially by the user device 102 and partially by the program manager device 106, or may be otherwise performed.
A determination may be made that an individual is a member of a drug benefit program for which a therapy implementation program is offered at block 502. The determination may be made, for example, by accessing the member data 110 from the database 108, e.g., to identify one or more characteristics of the drug benefit program to which the member belongs. In some embodiments, the determination that the individual is member of a drug benefit program for which the therapy implementation program is offered may also include accessing the program data 112 from the database 108. In some embodiments, the program data may indicate the drug benefit programs for which the therapy implementation programs are offered.
In some embodiments, an early phase communication may be sent (e.g., transmitted) to the member enrolled in a drug benefit program for which the therapy implementation program is offered. The early phase communication may include information regarding a therapy implementation program. The information regarding the therapy implementation program may include, for example, information regarding benefits of participation, eligibility requirements for participating in the therapy implementation program, deadlines for enrolling in the therapy implementation program and the like. The early phase communication may be transmitted to one, or more than one, members of the drug benefit program. The early phase communication may include a mail-based communication (e.g., a letter, a postcard, or the like), a telephonic communication (e.g., an automated telephone call or an in-person call, or the like), an electronic communication (e.g., an email), or other communication. In some embodiments, more than one early phase communication may be transmitted.
The applicability of a deadline for making a decision regarding participation in the therapy implementation program may be determined at block 504. In some embodiments, determining the applicability of the deadline may include accessing the member data 110 and comparing the member data 110 to one, or more than one, therapy implementation program criterion associated with the decision deadline. For example, the therapy implementation program criterion, which may be included in the program data 112, may indicate one or more member characteristics that may require that the member make a decision regarding participation, or non-participation, in the therapy implementation program. For example, the therapy implementation program criterion may include a prescription history for prescription drugs included as back-up drugs within a step therapy program, a prescription history for specialty drugs, a prescription history for non-formulary drugs, or the like. In some embodiments, all members within a drug benefit program may be required to make a decision regarding participation, or non-participation, in the therapy implementation program.
In some embodiments, accessing the member data 110 may include accessing the member data 110 from the database 108. In some embodiments, accessing the member data 110 may include receiving the meeting data. For example, the member data 110 may be received directly from the database 108 and/or may be received from the database 108 via the network 104.
A notification that the member qualifies and/or is eligible for a therapy implementation program may be generated at block 506. The notification may be generated based on the determination that the member qualifies and/or is eligible for the therapy implementation program, and that the decision deadline is applicable to the member. In some embodiments, the notification may be a targeted notification, which may be transmitted to members determined to qualify for the therapy implementation program. The notification may include information regarding the therapy implementation program, such as benefits and savings that may be obtained through participation in the therapy implementation program. In some embodiments, the notification may include an indication of a deadline for making a decision regarding participation in the therapy implementation program and consequences for not making choice to either participate in the therapy implementation program or to not participate in the therapy implementation program.
In some embodiments, the notification may be transmitted to all members of a health plan and/or may be transmitted to a subset of members of the health plan. In some embodiments, the notification may be transmitted as a mail-based notification, such as a letter, a postcard, or the like. In some embodiments, the notification may be a telephonic notification, such as an automated telephone notification or an in-person telephone notification. In some embodiments, the notification may include an electronic notification, such as an email. Other notifications may be utilized.
The occurrence of the decision deadline may be determined at block 508. Determining the occurrence of the decision deadline may be based on, for example, the time period specified within the notification.
A determination that a decision regarding participation in the therapy implementation program may be made at block 510. In an example embodiment, it may be determined that a response regarding participation in the therapy implementation program has not been received in response to the notification and in response to the determination of the occurrence of the decision deadline.
A suspension of an aspect of a benefit of the drug benefit program may be generated at block 512. In an embodiment, the suspension of the aspect of the benefit may be generated based on the determination that the decision deadline has occurred and the determination that a response regarding participation in the therapy implementation program has not been received. For example, the aspect of the benefit may include a prescription drug selection benefit available to the member, a pharmacy network selection benefit available to the member, and/or a prescription drug delivery channel benefit available to the member. Suspending the aspect of the benefit may include, for example, suspending coverage, or at least a portion of the coverage, for the aspect of the benefit under the drug benefit program.
An intervention may be implemented at block 510 based on the determination that an enrollment designation has not been received. In some embodiments, implementing the intervention may be based on receipt of a prescription fill and/or refill request. For example, a member who has not made a choice whether to participate in a therapy implementation program by a deadline for receiving an enrollment decision may attempt to refill a prescription, for example at a retail pharmacy, or otherwise. The pharmacy may submit a claim (e.g., to the PBM), indicating a request for a refill of the prescription. Implementing the intervention may be in response to the receipt of the request to refill the prescription.
In some embodiments, implementing the intervention may include generating an intervention notification. In some embodiments, the intervention notification may be a notification to the member that an action is required by the member, such as contacting a health plan representative. In some embodiments, the intervention notification may include a denial to refill the prescription under the drug benefit program. In some embodiments, implementing the intervention make the member subject to a modified co-payment associated with the fill and/or refill of the prescription, such as an increased co-payment and/or payment of a full retail cost associated with the prescription.
In some embodiments, the intervention may be stored through the member data 110, the program data 112, or may otherwise be stored and/or implemented.
FIG. 6 illustrates a method 600 for promoting therapy implementation programs and increasing participation in therapy implementation programs, according to an example embodiment. The method 600 may be performed by the user device 102, partially by the user device 102 and partially by the program manager device 106, or may be otherwise performed.
In an embodiment, it may be determined that a member qualifies for a therapy implementation program at block 602. In some embodiments, the determination that the member qualifies for the therapy implementation program may include accessing the member data 110 and comparing the member data 110 to a therapy implementation program criterion (e.g., which may be included in the program data 112). The member data 110 may be compared to a single therapy implementation program criterion or multiple therapy implementation program criteria.
A notification that the member qualifies for the therapy implementation program may be generated at block 604. In some embodiments, the notification may indicate that the member is required to make a decision to participate, or to not participate, in the therapy implementation program be a specified decision deadline.
It may be determined that a decision response has not been received from the member before the occurrence of the decision deadline at block 606. In some embodiments, the determination that a decision response has not been received may be based on a determination that a decision deadline specified n the notification has occurred.
An aspect of a benefit of the drug benefit program may be altered at block 608, based on the determination that a decision response has not been received. In an embodiment, the aspect of the benefit that may be altered may include a retail pharmacy coverage aspect of the drug benefit program. The retail pharmacy coverage aspect of the drug benefit program may, for example, control what prescription drugs may be covered by the drug benefit program when purchased at a retail pharmacy as opposed to being purchased via a home delivery pharmacy. In an embodiment, the aspect of benefit that may be altered may include a pharmacy network selection coverage aspect of the drug benefit program. The pharmacy network selection coverage aspect of the drug benefit program may, for example, control what pharmacies prescription drugs may be purchased at an be covered under the drug benefit program. In an embodiment, the aspect of the benefit that may be altered may include a prescription drug selection aspect of the drug benefit program. The prescription drug selection aspect of the drug benefit program may control what prescription drugs may be covered by the drug benefit program, for example in a case in which more than one drug may be suitably utilized to treat a disease, condition, or the like.
An intervention may be implemented at block 610. In general, the intervention may be implemented, for example, when the member seeks coverage for an altered aspect of the benefit under the drug benefit program. For example, the intervention may be implemented when the member attempts to fill and/or refill a prescription. In some embodiments, implementing the intervention may include receiving a request for a fill and/or refill of a prescription by the member. The intervention may include, for example, a denial of coverage for the fill and/or refill of the prescription, an increased co-pay for the fill and/or refill of the prescription, or the like.
In an example embodiment, the therapy implementation program may include a pharmacy network selection program. In an example pharmacy network selection program, the pharmacy network selection may offer significant savings to a member. FIG. 7 is a chart 700 of example pharmacy networks that may be available in a particular plan. The pharmacy networks available in the particular plan may include value-enhanced networks (e.g., the 30K network 702 and the 40K network 704) that may offer savings on prescriptions filled within the corresponding networks. The value-enhanced networks may be limited to select pharmacies and chains, as compared to a standard network (e.g., the 50K network 706).
While members may generally object to being forced to utilize a more limited selection of pharmacies included within a value-enhanced network. However, some members may already be using a pharmacy within a value-enhanced network, and, as such, the selection of a value-enhanced may not significantly effect such members. Accordingly, by promoting an affirmative choice of pharmacy network by members, the usage of value-enhanced pharmacies by a set of members may be increased, once the set of members is educated to understand that the selection of a value-enhanced pharmacy network may not significantly affect the pharmacies that are actually utilized by the members. Therefore, allowing to members to have the choice of pharmacy network may, at least in part, alleviate any discontent of the members, as opposed to being forced to choose a value-enhance pharmacy network by a health plan sponsor. Thus by promoting an active selection of a pharmacy network, a health plan sponsor may continue to offer a variety of pharmacy networks, but individual members participating in the health plan, by affirmatively selecting a pharmacy network, may be more likely utilize the pharmacy network that best suits the needs of the individual members. Often, the pharmacy network that best suits the needs of the individual members may be a value-enhanced pharmacy network.
FIG. 8 is an example communication timeline 800 that may be used in connection with a pharmacy network selection program. In the example embodiment, individual members, or groups of members, may receive early phase communications 802, 804, for example at two months prior to implementation of the pharmacy network selection program and at one month prior to implementation of the pharmacy network selection plan, respectively. In some embodiments, the early phase communications 802, 804 may, for example, inform a member that he or she has a choice of pharmacy networks; inform the member of the benefits of use of a value enhanced pharmacy (e.g., lower costs and protection of the pharmacy benefit for the set of individuals); inform the member of methods of making a pharmacy network selection; inform the member of a decision deadline for making a pharmacy network selection; and/or inform the member of the consequences of failing to make a pharmacy network selection before a decision deadline has passed. Additional and/or alternative information may be included within the early phase communication 802, 804.
In some embodiments, one or more targeted communications (e.g., early phase communication 804) may be directed to members who fail to make an affirmative selection of pharmacy network within a particular time frame, e.g., within approximately one month prior to implementation. In some embodiments, if the member does not make a decision by a decision deadline (e.g., at implementation of the therapy implementation program), an intervention may be imposed if a member attempts to fill and/or refill a prescription at a pharmacy that is not in a value-enhanced pharmacy network. For example, filling and/or refilling the prescription may be denied coverage under the drug benefit program. In some embodiments, the member may make a selection to participate in the value-enhanced pharmacy network or to not participate in the value-enhanced pharmacy network after the intervention has been imposed. In some embodiments, once the intervention has been imposed, the member may be required to participate in the value-enhanced pharmacy network. In some embodiments, if the member chooses not to participate in the value-enhanced pharmacy network the member may be subject to a higher co-pay than if the member chooses to participate in the value-enhanced pharmacy network.
In some embodiments, an active decision is promoted by implementing a default enrollment in the value-enhanced pharmacy network in the absence an alternative choice by the member, enrolling the member in the most value-enhanced pharmacy network, for example the 30K pharmacy network 702, shown in FIG. 7. In one embodiment, no penalty is imposed for selection of a different network, other than loss of cost savings from a more value-enhanced network. Accordingly, by using systems and methods for promoting therapy implementation programs promote an affirmative choice of a pharmacy network by members, members may be more likely to actively select a pharmacy network and, therefore, may be more likely to select a pharmacy network that is best suited to the particular cost/convenience needs of the member. Accordingly, the methods and systems may be directed primarily to promoting an affirmative choice rather than a particular affirmative choice. However, some embodiments may incorporate methods of promoting a particular choice, such as a co-pay differential based on the selected pharmacy network.
In an example embodiment, the therapy implementation program may include a specialty pharmacy program. A specialty pharmacy may, for example, include a pharmacy that provides services to members with acute or chronic conditions that can be treated at home, in a physician's (or other caregiver's) office, or at specialized infusion sites. Further, a specialty pharmacy may include a company that works with customers to manage use of high-cost drugs used to treat chronic diseases; and/or may include a provider of pharmacy services for people with complex chronic health conditions.
In an embodiment, the use of a mail order specialty pharmacy to fill prescriptions of specialty drugs may provide significant advantages for members, as compared to the use of a retail pharmacy for such purpose. In addition to other general benefits of home delivery, such as increased adherence, the use of a specialty mail order pharmacy to fill prescriptions for specialty drugs may provide benefits such as increased access to clinical experts, increased patient satisfaction, and simplified refill processes.
FIG. 9 is an example timeline 900 of communications that may be used in connection with promoting a specialty pharmacy therapy implementation program. Communications and/or notifications (including early phase communications and/or targeted notifications) may utilize various communications channels. For example, mail-based communications may include postcards 902, letters 904, and mailers 908. Telephone communications may include, for example, an automated call 906. Various additional and/or alternative communication channels may be utilized.
In an embodiment, one or more of the communications carried out in the timeline 900 of communications may, for example, inform a member that he or she has a choice of filling prescriptions for specialty drugs at a specialty pharmacy or at retail; inform the member of the benefits of using a specialty pharmacy; and/or inform the member of methods of making a specialty pharmacy selection. Various additional and/or alternative information may be included within one or more of the communications 902-908.
In an embodiment, targeted communications may be directed to one, or more than one, members who have previously filled one, or more than one, prescriptions for a specialty drug at retail and/or who have failed to make an affirmative selection of the type of pharmacy to use for future fills of specialty drugs. Targeted communications may include one or more of the communications 902-908 shown in FIG. 8.
In some embodiments, if the member does not make a decision by a decision deadline, the member may be subject to a retail intervention. For example, if the member attempts to fill and/or refill a prescription for a specialty drug after the decision deadline, coverage for the prescription under the drug benefit program may be denied. In some embodiments, if the member is subject to the retail intervention, the member may make a selection to participate in the specialty pharmacy therapy implementation program or to not participate in the specialty pharmacy therapy intervention program after the intervention has been imposed. In some embodiments, once the intervention has been imposed (and/or the decision deadline has occurred), the member may be required to participate in the specialty pharmacy therapy implementation program.
In some embodiments, if a member fails to make a choice to participate in the specialty pharmacy therapy implementation program, or chooses to not participate in the specialty pharmacy therapy implementation program, a retail intervention may be implemented to promote and encourage use of specialty pharmacy to fill prescriptions for specialty drugs. For example, a fill and/or a refill of a prescription for specialty drugs may be declined, and/or the member may be required to pay a full retail price, or an increased co-pay amount, for the specialty drugs. In some embodiments, an automated call (for example, automated call 906) or other interactive communication may be used to communicate with a targeted member who has failed to make an affirmative decision regarding a pharmacy for future fills of specialty drugs. In some embodiments, a therapy implementation program promotion system may receive an input representing an affirmative decision by the member during and/or as a result of such a targeted communication.
FIG. 10 is a flowchart 1000 of an embodiment of a therapy implementation program promotion system implemented to cause an affirmative selection of a pharmacy type utilized to fill prescriptions for specialty drugs. For example, in response to one or more of the communications 902-908 a member may call a representative for PBM or specialty pharmacy program administrator, or the like, at block 1002. When the member calls the representative, the member may be educated about the benefits of the specialty pharmacy program and services available under the program. If the member chooses to enroll in the specialty pharmacy program at block 1004, the member may convert their specialty pharmacy needs to the specialty pharmacy at block 1006, and may be provided with enrollment information concerning the specialty pharmacy program. The member may thereafter receive personalized care from the specialty pharmacy at block 1008. The personalized care may include, for example, receiving fills of prescriptions for specialty drugs from the specialty pharmacy and/or otherwise in accordance with the specialty pharmacy program.
When the member calls the representative, the member may choose not to enroll in the specialty pharmacy program, and to continue receiving specialty pharmacy services and fills of prescriptions for specialty drugs from a retail pharmacy at block 1010. Thereafter, a patient care advocate may assist the member with receiving specialty pharmacy services and/or fills of prescriptions for specialty drugs at block 1012, including, in some embodiments, providing a 365 day prior authorization (PA) override, allowing the member to receive specialty pharmacy services and/or fills of prescriptions for specialty drugs at a retail pharmacy. A notification may be sent to the member ninety days prior to the expiration of the prior authorization, at block 1014. Similarly, reminder letters (or other communications and/or notifications) may be sent to the member sixty and thirty days prior to the expiration of the prior authorization at block 1016. The communications 1014, 1016 may alert the member to the impending expiration of the prior authorization and notify the member of the availability of the specialty pharmacy program. After 365 days from the time the member made the decision to continue receiving specialty pharmacy services and/or fills of prescriptions for specialty drugs was made (e.g., at block 1002) the prior authorization may expire at block 1018. When the prior authorization expires at block 1018, the member may be required to enroll in the specialty pharmacy program. If the member does not enroll in the specialty pharmacy program, the member may be required to pay full retail price (and/or an greater co-pay) for specialty pharmacy services and/or fills of prescriptions for specialty drugs.
In an embodiment, the therapy implementation program may include a step therapy program. A step therapy program may generally refer a program that may be directed for people who take prescription drugs regularly, for example to treat ongoing medical conditions, such as arthritis and high blood pressure. In an embodiment, a step therapy program may include medications that are grouped and/or ranked based on cost. A first group of drugs (a “front line' group) may include drugs for which there is significant history of use in connection with a particular condition. Front-line drugs may often be, but are not necessarily, so-called generic drugs. A second group of drugs (a “back-up,” or non-preferred group of drugs) may include newer and/or more expensive drugs. The second, or ‘back-up,” group may be further segregated into sub-groups.
In an embodiment of a step therapy program, health plan of a member may require that the member utilize front-line drugs (to the extend available) for the treatment of a condition. In such an embodiment, coverage for a back-up drug may be denied in favor of a front line drug, consistent with terms of the health plan. Denial of coverage for back-up drugs may be overridden (and coverage may thereby be allowed) if the front line drug is contraindicated (e.g., due to drug allergy), and/or based on a physician's recommendation. Accordingly, a prescription for a back-up drug for a member participating in a step therapy program may be filled instead with a front line drug. If the front line drug does not satisfactorily treat condition for which the drug is prescribed, a back-up drug may be covered by the pharmacy benefit plan associated with the health plan of which the member is a participant.
Systems and methods for promoting therapy implementation programs may be utilized, in consideration that mandatory implementation of a step therapy program by a health plan sponsor may be met with resistance by members participating in the health plan. Methods and systems for promoting a step therapy program may promote an affirmative decision by members to either participate, or to not participate, in a step therapy program.
FIG. 11 is a communication timeline 1100 that may be utilized in connection with the promotion of an example step therapy program. One, or more than one, communications and/or notifications (e.g., a communication 1102 two months prior to the implementation of the step therapy program and the notification 1104 one month prior to implementation of the step therapy program) may be transmitted to a member, and/or a group of members, to whom the step therapy program is being promoted. In some embodiments, the communications may be directed to all members of a drug benefit program sponsored by a client. In some embodiments, the communications may be targeted to particular members, e.g., who may be undergoing treatment that may be subject to the step therapy program. In some embodiments, the communications may be targeted to particular members, e.g., who may have been prescribed a non-preferred drug (such as a back-up drug). In some embodiments, the communications may be targeted to particular members, e.g., who may have been prescribed a particular non-preferred drug.
The communications and/or notifications may inform a member that he or she has a choice of participating in a step therapy program; inform the member of the benefits of use of step therapy program (e.g., lower costs); inform the member of methods of making a decision about participation in a step therapy program; inform the member of a decision deadline; and/or inform the member of the consequences of failing to make a decision regarding participation in a step therapy program before a decision deadline has passed.
In some embodiments, one or more targeted communications and/or notifications (e.g., the notification 1104 one month prior to implementation of the step therapy program) may be transmitted to members who fail to make an affirmative decision regarding participation in the step therapy program within a particular time frame (e.g., within approximately 1 month prior to the implementation of the step therapy program).
In some embodiments, if the member does not make a decision by a decision deadline (e.g., at implementation of the therapy implementation program), an intervention may be imposed if a member attempts to fill and/or refill a prescription for a non-preferred drug. For example, filling and/or refilling the prescription may be denied coverage under the drug benefit program. In some embodiments, the member may make a selection to participate in the step therapy program or to not participate in the step therapy program after the intervention has been imposed. In some embodiments, an active decision is promoted by providing for a default enrollment for participation of the member in the step therapy program, absent an alternative choice by the member. For example, in such an embodiment, once the intervention has been imposed (and/or the decision deadline has occurred), the member may be required to participate in the step therapy program. In some embodiments, if the member chooses not to participate in the step therapy program the member may be subject to a higher co-pay than if the member chooses to participate in the step therapy program. In one embodiment, an additional lower co-pay incentive may be included to promote participation in a step therapy program. In an embodiment, as coverage for back-up drugs may be initially denied for members participating in a step therapy program, when a member attempts to fill a prescription for a back-up drug, the prescription may be converted to a front line drug and/or the member may be responsible for payment of the full retail price of the back-up drug, and/or for payment of a higher co-pay as compared to a corresponding front line drug.
In one embodiment, automatically generated early and targeted communications are used to obtain an individual's pre-commitment to use generic or other lower-cost drug alternatives.
In an embodiment, a therapy implementation program being promoted may include a drug selection consultation program. For example, a member filling and/or refilling a prescription for a non-formulary drug at a retail pharmacy may receive one or more targeted communications, based on the prescription for the non-formulary drug, informing the member of possible savings that may be associated with transferring to a formulary drug and/or transferring fills of prescriptions to a home delivery pharmacy. In some embodiments, the communication may include a mail-based communication, an automated telephone communication, or the like. The communication may invite the member to contact a patient care advocate for a savings consultation (e.g., including benefits associated with changing to a formulary drug) in order to avoid interruption of coverage.
In an embodiment, if the member contacts the patient care advocate for the savings consultation (e.g., either in response to the communications and/or in response to the intervention), the member may be permitted to choose to continuing using the non-formulary drug. In such an embodiment, the member may receive a prior authorization override, to permit coverage of the non-formulary drug under a health plan in which the member participates. In some embodiments, the member may choose, for example, to continuing filling prescriptions for non-formulary drugs at retail; to continue filling prescriptions for non-formulary drugs, but to receive the prescription fills via home delivery; to switch to a formulary drug and fill prescriptions for the formulary drug at retail; and/or to switch to a formulary drug and fill prescriptions via home delivery.
If the member does not respond to the communications (e.g., by a deadline for responding specified in the communication, and/or within a specified number of fills of the prescription for the non-formulary drug), an intervention may be implemented. In an example embodiment, the intervention may be a denial of coverage for the non-formulary drug. A denial of coverage may necessitate that the member pay a full retail price for the non-formulary drug, and/or that the member pay an enhanced co-pay for the non-formulary drug. In some embodiments, once the intervention has been imposed, the member may contact the patient care advocate and make a selection regarding the usage of the non-formulary drug. In some embodiments, once the intervention has been imposed, the member may be required to participate in the drug selection consultation program, for example, only being allowed to select one, or a subset, of the available options (e.g., to switch to a formulary drug and to receive the formulary drug via home delivery).
In an embodiment, a therapy implementation program being promoted may include an adherence program. The adherence program may generally be directed at improving adherence of members to prescribed courses of treatment. In some embodiments, early phase communications may be transmitted to a member, and/or a group of members. The early phase communications may inform the members of the importance of adhering to prescribed courses of treatment; programs, such as home delivery, that may facilitate adherence, and the like.
In some embodiments, one or more communications and/or notifications may be transmitted to members undergoing a prescribed course of treatment (e.g., for a chronic condition, or condition requiring a relatively long term course of treatment). In some embodiments, one or more communications and/or notifications may be targeted to members utilizing retail pharmacies based on their medication possession ratio, or other adherence metric (e.g., which may be based on a frequency at which a prescription is refilled as compared to the intended time period of treatment provided by a fill of the prescription, or other suitable criteria). In some embodiments, members exhibiting acceptable levels of adherence (e.g., a medication possession ratio of 80% or greater) may receive a communication commending their adherence. Members exhibiting less than acceptable levels of adherence (e.g., a medication possession ratio of less than 80%) may receive a communication informing the member of programs that may facilitate improved adherence, such as home delivery of prescription drugs, and/or enrollment information by which the member can enroll in such programs.
In some embodiments, members exhibiting less than acceptable levels of adherence that do not enroll in a program to facilitate improved adherence may be subject to intervention. For example, a member utilizing a retail pharmacy to fill prescriptions that has not made a decision to enroll in a program for improving adherence, such as home delivery of prescription drugs, may be denied coverage (e.g., may be required to pay the entire retail price for the prescription and/or may be required to pay an higher co-pay) at the retail pharmacy. In some embodiments, the member may receive additional communication regarding participation in one or more programs to facilitate improved adherence, and/or an in person consultation from a representative of the PBM, health plan sponsor, or the like.
In an example embodiment, the therapy implementation program may include a home delivery program program. In an example embodiment, the home delivery program, may enable the member to receive fills and/or refills of prescriptions for drugs associated with a relatively long term course of treatment (e.g., maintenance drugs for an ongoing condition, or the like) via home delivery from a mail order pharmacy. The member may be required to choose to receive the fills and/or refills of the prescription at retail and/or via home delivery. In some embodiments, the PBM client may be capable of realizing significant saving when members utilize home delivery for prescriptions for drugs associated with a relatively long-term course of treatment.
In an embodiment, one, or more than one, communications may be transmitted to the member regarding the option to choose to receive prescriptions for drugs associated with relatively long term courses of treatment via home delivery. The communications may include, for example, descriptions of the benefits that the member may realize by using home delivery, such as the convenience of having the prescriptions delivered to the members home as opposed to the member having to pick the prescriptions up at a retail pharmacy, and potential cost savings to the member. The communications may, for example, precede a decision deadline by which the member must decide to participate, or to not participate, in the home delivery program.
In some embodiments, one or more targeted communications may be directed to members filling and/or refilling prescriptions for drugs associated with a relatively long-term course of treatment. In some embodiments, communications may be directed to all members, or a subset of members, participating in a drug benefit program sponsored by a given client. In some embodiments, one, or more than one, targeted communications may be directed to members who fail to make an affirmative selection of pharmacy network within a particular time frame, e.g., within approximately one month prior to implementation of the home delivery program. In some embodiments, if the member does not make a decision by a decision deadline (e.g., at implementation of the therapy implementation program), an intervention may be imposed if a member attempts to fill and/or refill a prescription for a drug associated with a relatively long-term course of treatment at a retail pharmacy. For example, filling and/or refilling the prescription may be denied coverage under the drug benefit program. In some embodiments, the member may make a selection to participate in the home delivery program, or to not participate in the home delivery program, after the intervention has been imposed. In some embodiments, once the intervention has been imposed (and/or the decision deadline has occurred), the member may be required to participate in the home delivery program, e.g., by being required to receive all drugs associated with a relatively long term course of treatment via home delivery. In some embodiments, the member may be granted a courtesy refill, e.g., to provide the member with the necessary prescription drugs until a home delivery of the prescription drugs can be made. In some embodiments, if the member chooses not to participate in the home delivery program the member may be subject to a higher co-pay than if the member chooses to participate in the home delivery program.
While various examples of therapy implementation programs have been described, including specific timelines and process flows, such examples have been described for the purpose of illustration and not of limitation. Various additional and/or alternative therapy implementation programs may be promoted using systems and methods described herein. Additionally, various additional and/or alternative timelines, communications and/or notifications, as well as other attributes, may be implemented in connection with the example therapy implementation programs described herein.
FIG. 12 shows a block diagram of a machine in the example form of a computer system 1200 within which a set of instructions may be executed causing the machine to perform any one or more of the methods, processes, operations, or methodologies discussed herein. The user device 102 and/or the program manager device 106 may include the functionality of the one or more computer systems 1200.
In an example embodiment, the machine operates as a standalone device or may be connected (e.g., networked) to other machines. In a networked deployment, the machine may operate in the capacity of a server or a client machine in server-client network environment, or as a peer machine in a peer-to-peer (or distributed) network environment. The machine may be a server computer, a client computer, a personal computer (PC), a tablet PC, a gaming device, a set-top box (STB), a Personal Digital Assistant (PDA), a cellular telephone, a web appliance, a network router, switch or bridge, or any machine capable of executing a set of instructions (sequential or otherwise) that specify actions to be taken by that machine. Further, while only a single machine is illustrated, the term “machine” shall also be taken to include any collection of machines that individually or jointly execute a set (or multiple sets) of instructions to perform any one or more of the methodologies discussed herein.
The example computer system 1200 includes a processor 1202 (e.g., a central processing unit (CPU) a graphics processing unit (GPU) or both), a main memory 1204 and a static memory 1206, which communicate with each other via a bus 1208. The computer system 1200 further includes a video display unit 1210 (e.g., a liquid crystal display (LCD) or a cathode ray tube (CRT)). The computer system 1200 also includes an alphanumeric input device 1212 (e.g., a keyboard), a cursor control device 1214 (e.g., a mouse), a drive unit 1216, a signal generation device 1218 (e.g., a speaker) and a network interface device 1220.
The drive unit 1216 includes a computer-readable medium 1222 on which is stored one or more sets of instructions (e.g., software 1224) embodying any one or more of the methodologies or functions described herein. The software 1224 may also reside, completely or at least partially, within the main memory 1204 and/or within the processor 1202 during execution thereof by the computer system 1200, the main memory 1204 and the processor 1202 also constituting computer-readable media.
The software 1224 may further be transmitted or received over a network 1226 via the network interface device 1220.
While the computer-readable medium 1222 is shown in an example embodiment to be a single medium, the term “computer-readable medium” should be taken to include a single medium or multiple media (e.g., a centralized or distributed database, and/or associated caches and servers) that store the one or more sets of instructions. The term “computer-readable medium” shall also be taken to include any medium that is capable of storing or encoding a set of instructions for execution by the machine and that cause the machine to perform any one or more of the methodologies of the present invention. The term “computer-readable medium” shall accordingly be taken to include, but not be limited to, solid-state memories, and optical media, and magnetic media. In some embodiments, the computer-readable medium is a non-transitory computer-readable medium.
The term “based on” or using, as used herein, reflects an open-ended term that can reflect others elements beyond those explicitly recited.
Certain systems, apparatus, applications or processes are described herein as including a number of modules. A module may be a unit of distinct functionality that may be presented in software, hardware, or combinations thereof. When the functionality of a module is performed in any part through software, the module includes a computer-readable medium. The modules may be regarded as being communicatively coupled.
The inventive subject matter may be represented in a variety of different embodiments of which there are many possible permutations.
In an example embodiment, it is determined that a member is enrolled in a drug benefit program. It is determined that a decision deadline has occurred for continuing an aspect of a benefit of the drug benefit program. It is determined that a decision response has not been received from the member. A suspension of the aspect of the benefit of the drug benefit program is generated based on the determination that the decision response has not been received from the member.
In an example embodiment, it is determined that a member of a drug benefit program qualifies for a therapy implementation program associated with the drug benefit program. A notification is generated for the member based on the determination that the member qualifies for the therapy implementation program. It is determined that a member response has not been received. An aspect of a benefit of the drug benefit program is altered based on the determination that the member response has not been received.
In an example embodiment, it is determined that a member of a drug benefit program qualifies for a prescription drug home delivery program associated with the drug benefit program. A notification for the member is generated based on the determination that the member qualifies for the prescription drug home delivery program. It is determined that a member response has not been received before the occurrence of a decision deadline. A retail pharmacy coverage aspect of the drug benefit program is altered based on the determination that the member response has not been received.
In an example embodiment, it is determined that a member of a drug benefit program qualifies for a value-enhanced pharmacy network program associated with the drug benefit program. A notification is generated for the member based on the determination that the member qualifies for the value-enhanced pharmacy network program associated with the drug benefit program. It is determined that a member response has not been received before the occurrence of a decision deadline. A pharmacy network selection coverage of the drug benefit program is altered based on the determination that the member response has not been received.
In an example embodiment, it is determined that a member of a drug benefit program qualifies for a prescription drug selection program associated with the drug benefit program. A notification for the member is generated based on the determination that the member qualifies for the prescription drug selection program. It is determined that a member response has not been received before the occurrence of a decision deadline. A prescription drug selection aspect of the drug benefit program is altered based on the determination that the member response has not been received.
Thus, methods and systems for implementation of therapy programs have been described. Although embodiments of the present invention have been described with reference to specific example embodiments, it will be evident that various modifications and changes may be made to these embodiments without departing from the broader spirit and scope of the embodiments of the invention. Accordingly, the specification and drawings are to be regarded in an illustrative rather than a restrictive sense.
The methods described herein do not have to be executed in the order described, or in any particular order. Moreover, various activities described with respect to the methods identified herein can be executed in serial or parallel fashion. Although “End” blocks are shown in the flowcharts, the methods may be performed continuously.
The Abstract of the Disclosure is provided to comply with 37 C.F.R. §1.72(b), requiring an abstract that will allow the reader to quickly ascertain the nature of the technical disclosure. It is submitted with the understanding that it will not be used to interpret or limit the scope or meaning of the claims. In addition, in the foregoing Detailed Description, it can be seen that various features are grouped together in a single embodiment for the purpose of streamlining the disclosure. This method of disclosure is not to be interpreted as reflecting an intention that the claimed embodiments require more features than are expressly recited in each claim. Rather, as the following claims reflect, inventive subject matter may lie in less than all features of a single disclosed embodiment. Thus, the following claims are hereby incorporated into the Detailed Description, with each claim standing on its own as a separate embodiment.

Claims

1. A method comprising:

determining, on a processor, that a member is enrolled in a drug benefit program;

determining, on the processor, that a decision deadline has occurred for continuing an aspect of a benefit of the drug benefit program;

determining, on the processor, that a decision response has not been received from the member; and

generating, on the processor, a suspension of the aspect of the benefit of the drug benefit program based on the determination that the decision response has not been received from the member.

2. The method according to claim 1, further comprising:

generating a notification that a decision response is required prior to the decision deadline; and

transmitting the notification to the member.

3. The method according to claim 2, further comprising:

determining that the decision deadline is applicable to the member; and

wherein generation the notification is in response to the determination that the decision deadline id applicable to the member.

4. The method according to claim 3, wherein determining that the decision deadline is applicable to the member comprises:

accessing member data associated with the member; and

comparing the member data associated with the member to therapy implementation program criterion associated with the decision deadline.

5. The method according to claim 1, further comprising:

implementing an intervention based on the generation of the suspension of the aspect of the benefit of the drug benefit program.

6. The method according to claim 5, wherein the aspect of the benefit includes a prescription drug selection benefit available to the member.

7. The method according to claim 5, wherein the aspect of the benefit includes a pharmacy network selection benefit available to the member.

8. The method according to claim 5, wherein the aspect of the benefit includes a prescription drug delivery channel benefit available to the member.

9. A method comprising:

determining, on a processor, that a member of a drug benefit program qualifies for a therapy implementation program associated with the drug benefit program;

generating, on the processor, a notification for the member based on the determination that the member qualifies for the therapy implementation program;

determining, on the processor, that a member response has not been received; and

altering, on the processor, an aspect of a benefit of the drug benefit program based on the determination that the member response has not been received.

10. The method of claim 9, wherein the aspect of the benefit of the drug benefit program includes a prescription drug selection available to the member.

11. The method of claim 9, wherein the aspect of the benefit of the drug benefit program includes a pharmacy network selection available to the member.

12. The method of claim 9, wherein the aspect of the benefit of the drug benefit program includes a prescription drug access channel available to the member.

13. The method of claim 9, further comprising:

receiving a prescription refill request by the member; and

implementing a pharmacy intervention based on the alteration of the aspect of the benefit of the drug benefit program and based on receipt of the prescription refill request by the member.

14. The method of claim 9, further comprising:

generating an early phase communication regarding the therapy implementation program.

15. A method comprising:

determining, on a processor, that a member of a drug benefit program qualifies for a prescription drug home delivery program associated with the drug benefit program;

generating, on the processor, a notification for the member based on the determination that the member qualifies for the prescription drug home delivery program;

determining, on the processor, that a member response has not been received before the occurrence of a decision deadline; and

altering, on the processor, a retail pharmacy coverage aspect of the drug benefit program based on the determination that the member response has not been received.

16. The method of claim 15, further comprising:

receiving a prescription refill request by the member; and

implementing a pharmacy intervention based on the alteration of the retail pharmacy coverage aspect of the drug benefit program and based on receipt of the prescription refill request by the member.

17. The method of claim 15, wherein the prescription drug home delivery program includes a specialty drug home delivery program.

18. A method comprising:

determining, on a processor, that a member of a drug benefit program qualifies for a value-enhanced pharmacy network program associated with the drug benefit program;

generating, on the processor, a notification for the member based on the determination that the member qualifies for the value-enhanced pharmacy network program associated with the drug benefit program;

altering, on the processor, a pharmacy network selection coverage of the drug benefit program based on the determination that the member response has not been received.

19. The method of claim 18, wherein altering the pharmacy network selection coverage comprises:

enrolling the member in the value-enhanced pharmacy network program.

20. The method of claim 19, further comprising:

receiving a prescription refill request by the member for a pharmacy not within the value-enhanced pharmacy network program; and

implementing a pharmacy intervention based on the enrollment of the member in the value-enhanced pharmacy network program.

21. A method comprising:

determining, on a processor, that a member of a drug benefit program qualifies for a prescription drug selection program associated with the drug benefit program;

generating, on the processor, a notification for the member based on the determination that the member qualifies for the prescription drug selection program;

altering, on the processor, a prescription drug selection aspect of the drug benefit program based on the determination that the member response has not been received.

22. The method of claim 21, wherein altering the prescription drug selection aspect of the drug benefit program comprises:

suspending coverage for non-formulary prescription drugs.

23. The method of claim 21, further comprising:

receiving a prescription refill request by the member; and

implementing a pharmacy intervention based on the alteration of the prescription drug selection aspect of the drug benefit program and based on receipt of the prescription refill request by the member.

24. A non-transitory machine-readable medium comprising instructions, which when executed by one or more processors, cause the one or more processors to perform the following operations:

determine that a member is enrolled in a drug benefit program;

determine that a decision deadline has occurred for continuing an aspect of a benefit of the drug benefit program;

determine that a decision response has not been received from the member; and

generate a suspension of the aspect of the benefit of the drug benefit program based on the determination that the decision response has not been received from the member.