Systems and methods for processing requests for pharmaceuticals that require insurer preapproval

A computer-readable medium storing a computer program product, executable by a computer, to process a request for a prescription for a predetermined pharmaceutical that requires preauthorization based upon clinical data of a patient, the computer program product comprising instructions for:

• (A) obtaining prescription information for the patient, wherein the prescription information comprises (i) an identity of the patient, (ii) an amount of the predetermined pharmaceutical, and (iii) a prescription for the amount of the predetermined pharmaceutical;
• (B) receiving patient clinical information, wherein the patient clinical information comprises one or more determinants of the patient and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to said patient for said predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;
• (C) storing the prescription information and the patient clinical information in electronic form;
• (D) sending the prescription information and the patient clinical information to a pharmacy that is configured to use the prescription information and the patient clinical information to make a coverage decision as to whether to grant coverage to said patient for said predetermined pharmaceutical, wherein said coverage decision made by the pharmacy is based upon (i) a set of guidelines provided by an insurer of the patient, (ii) the prescription information, and (iii) the patient clinical information;
• and
• (E) communicating the coverage decision to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, or a local or remote computer system;
• or displaying the coverage decision in a user readable form.

An apparatus for processing a request for a prescription for a predetermined pharmaceutical that requires preauthorization based upon clinical data of a patient, the apparatus comprising:

• a processor;
• and
• a memory, coupled to the processor, the memory storing a module comprising instructions for:
• (A) obtaining prescription information for the patient, wherein the prescription information comprises (i) an identity of the patient, (ii) an amount of the predetermined pharmaceutical, and (iii) a prescription for the amount of the predetermined pharmaceutical;
• (B) receiving patient clinical information, wherein the patient clinical information comprises one or more determinants of the patient and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to said patient for said predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;
• (C) storing the prescription information and the patient clinical information in electronic form;
• (D) sending the prescription information and the patient clinical information to a pharmacy that is configured to use the prescription information and the patient clinical information to make a coverage decision as to whether to grant coverage to said patient for said predetermined pharmaceutical, wherein said coverage decision made by the pharmacy is based upon (i) a set of guidelines provided by an insurer of the patient, (ii) the prescription information, and (iii) the patient clinical information;
• and
• (E) communicating the coverage decision to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, or a local or remote computer system;
• or displaying the coverage decision in a user readable form.

A method for managing a plurality of patients that are each in need of a predetermined pharmaceutical that requires preauthorization based upon patient clinical data, the method comprising:

• (A) obtaining prescription information for each respective patient in the plurality of patients, wherein the prescription information comprises an identity of the respective patient and an amount of the predetermined pharmaceutical that has been prescribed to the patient;
• (B) receiving clinical information associated with each respective patient in the plurality of patients, wherein the clinical information for each respective patient comprises one or more determinants and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to the respective patient for the predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;
• (C) storing the prescription information and the clinical information in electronic form;
• (D) requesting coverage for a patient in the plurality of patients for the predetermined pharmaceutical by transmitting the prescription information and the clinical information to a specialty pharmaceutical distributor at a remote location by electronic means;
• and
• (E) communicating a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, a local or remote computer system, or a record associated with the patient;
• or displaying a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical in a user readable form.

A computer-readable medium storing a computer program product, executable by a computer, to manage a plurality of patients that are each in need of a predetermined pharmaceutical that requires preauthorization based upon patient clinical data, the computer program product comprising instructions for:

• (A) obtaining prescription information for each respective patient in the plurality of patients, wherein the prescription information comprises an identity of the respective patient and an amount of the predetermined pharmaceutical that has been prescribed to the patient;
• (B) receiving clinical information associated with each respective patient in the plurality of patients, wherein the clinical information for each respective patient comprises one or more determinants and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to the respective patient for the predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;
• (C) storing the prescription information and the clinical information in electronic form;
• (D) requesting coverage for a patient in the plurality of patients for the predetermined pharmaceutical by transmitting the prescription information and the clinical information to a specialty pharmaceutical distributor at a remote location by electronic means;
• and
• (E) communicating a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, a local or remote computer system, or a record associated with the patient;
• or displaying a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical in a user readable form.

An apparatus for managing a plurality of patients that are each in need of a predetermined pharmaceutical that requires preauthorization based upon patient clinical data, the apparatus comprising:

• a processor;
• and
• a memory, coupled to the processor, the memory storing a module comprising instructions for:
• (A) obtaining prescription information for each respective patient in the plurality of patients, wherein the prescription information comprises an identity of the respective patient and an amount of the predetermined pharmaceutical that has been prescribed to the patient;
• (B) receiving clinical information associated with each respective patient in the plurality of patients, wherein the clinical information for each respective patient comprises one or more determinants and wherein each determinant in the one or more determinants contributes to a basis for authorizing or denying coverage to the respective patient for the predetermined pharmaceutical, and wherein at least one determinant in the one or more determinants is not a standardized code;
• (C) storing the prescription information and the clinical information in electronic form;
• (D) requesting coverage for a patient in the plurality of patients for the predetermined pharmaceutical by transmitting the prescription information and the clinical information to a specialty pharmaceutical distributor at a remote location by electronic means;
• and
• (E) communicating a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical to a user interface device, a monitor, a computer-readable storage medium in tangible form, a computer-readable memory, a local or remote computer system, or a record associated with the patient;
• or displaying a grant or denial of coverage for a patient in the plurality of patients for the predetermined pharmaceutical in a user readable form.