Methods and systems for maintaining pharmacy provider networks

A non-transitory machine-readable medium storing instructions for filling a prescription over a network, which, when executed by one or more processors, cause the one or more processors to:

• selecting a variable number for an acute medication threshold number of available fills for each drug available in the network;
• access claims adjudication data associated with a member and a prescribed drug;
• determine whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills using the claims adjudication data;
• classify the prescribed drug associated with the member as one of an acute medication and a maintenance medication based on the determination of whether the number of available fills of the prescribed drug exceeded the acute medication threshold number of available fills;
• associate the prescribed drug with a type of pharmacy provider network based on classification of the prescribed drug, the type of pharmacy provider network being an acute medication pharmacy provider network or a maintenance medication pharmacy provider network;
• determine whether a pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network associated with the prescribed drug;
• adjudicate a pharmacy claim for the prescribed drug through the pharmacy based on the pharmacy claim and a determination of whether the pharmacy is included within the type of pharmacy provider network;
• transmit, from the processor over a network, an adjudication response from adjudication based adjudicating the pharmacy claim;
• and
• receive, at a pharmacy device of the pharmacy, the adjudication response;
• and
• authorizing a filling of the prescription for the member at the pharmacy after receipt of the adjudication response associated with the member to execute a physical filling of the prescription for the member at the pharmacy.

A method for filling a prescription comprising:

• receiving, on a processor, a pharmacy claim to adjudicate, the pharmacy claim associated with a member and a prescribed drug;
• remotely selecting an acute medication threshold number of available fills, which is a selectable variable;
• transmitting the acute medication threshold number of available fills to the processor;
• classifying, on the processor, the prescribed drug associated with the member as a maintenance medication based on a determination of whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills;
• determining, on the processor, that a pharmacy associated with a request to adjudicate the pharmacy claim is included within an acute medication pharmacy provider network;
• and
• transmitting, on the processor, a warning that a modified set of member benefits are associated with filling the prescribed drug at the pharmacy based on classification of the prescribed drug as a maintenance medication and a determination that the pharmacy is included within the acute medication pharmacy provider network;
• transmitting, from the processor over a network, an adjudication response from adjudication based adjudicating the pharmacy claim;
• receiving, at a pharmacy device of the pharmacy, the adjudication response;
• authorizing a filling of the prescription for the member at the pharmacy after receipt of the adjudication response associated with the member;
• and
• filling the prescription at the pharmacy after receipt of the adjudication response.

A pharmacy system for transmitting a prescription comprising:

• a plurality of pharmacies including a first pharmacy provider device in an acute medication pharmacy provider network and a second pharmacy provider device in a maintenance medication pharmacy provider network;
• a manager device to select, from a variable, an acute medication threshold number of available fills and to transmit the acute medication threshold number of available fills for storage in a database on the memory;
• and
• an adjudicator subsystem including:
• a data access device to retrieve, via electronic communication, claims adjudication data associated with a member and a prescribed drug stored in a memory;
• an analysis device to determine whether a number of available fills of the prescribed drug exceeds the acute medication threshold number of available fills that is stored in a database on the memory;
• a classification device to classify the prescribed drug associated with the member as one of an acute medication and a maintenance medication based on a determination of whether the number of available fills of the prescribed drug exceeded the acute medication threshold number of available fills;
• a network determination device to associate the prescribed drug with a type of pharmacy provider network based on classification of the prescribed drug, the type of pharmacy provider network being the acute medication pharmacy provider network or the maintenance medication pharmacy provider network, wherein the network determination device is to determine whether a pharmacy associated with the claims adjudication data is included within the type of pharmacy provider network associated with the prescribed drug;
• an adjudication device to adjudicate a pharmacy claim for the prescribed drug through the pharmacy based on the pharmacy claim and a determination of whether the pharmacy is included within the type of pharmacy provider network;
• and
• a transmission device to transmit, over an electronic communication network, an adjudication response from the adjudication device based adjudicating the pharmacy claim to at least one of the plurality of pharmacies of either the first pharmacy provider device or the second pharmacy provider device, but not both the first pharmacy provider device and the second pharmacy provider device;
• wherein the at least one of the plurality of pharmacies of either the first pharmacy provider device or the second pharmacy provider device is to receive, at a pharmacy device, the adjudication response with an authorization for filling of the prescription for the member;
• and
• wherein the at least one of the plurality of pharmacies fills the prescription upon receipt of the adjudication response with an authorization for filling of the prescription.