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

A non-transitory computer-readable medium storing a computer program product, executable by a computer comprising a user interface device having a user input device and a display device, to process a request for a prescription solely for the specialty pharmaceutical palivizumab, the computer program product comprising instructions for causing the computer steps of:

• (A) obtaining with the user interface device prescription information for palivizumab for a patient, the instructions causing the display device to display an electronic form dedicated to receiving the prescription information solely for palivizumab, wherein the prescription information comprises a plurality of elements, the electronic form comprising blocks for receiving via the user input device elements comprising (i) information identifying the patient, and (ii) prescription for an amount of palivizumab;
• (B) receiving with the user interface device patient clinical information, the instructions causing the display device to display an electronic form dedicated to receiving the patient clinical information relevant to palivizumab, wherein the patient clinical information comprises a plurality of determinants which collectively assist in determining whether a patient is a good candidate for palivizumab and contribute to a basis for authorizing or denying coverage to said patient for palivizumab, the electronic form comprising at least five blocks for receiving via the user input device a corresponding at least five determinants from the group of determinants consisting of
• a gestational age of the patient,
• a weight of the patient,
• a categorical indication as to whether the patient has congenital heart disease,
• a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,
• a categorical indication as to whether the patient has a chronic pulmonary disease,
• a categorical indication as to whether the patient has a congenital anomaly of the respiratory system, and
• for at least one of said categorical indications, one or more additional determinants associated with the categorical indication;
• wherein at least one determinant is not a standardized code;
• (C) storing the prescription information and the patient clinical information in a non-transitory computer-readable medium;
• (D) requesting approval for the patient for palivizumab by sending the prescription information and the patient clinical information from the computer to a specialty 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 palivizumab, 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) displaying with the display device the coverage decision made by the pharmacy.

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

• a user interface device comprising a user input device and a display device;
• a processor coupled to the user interface device;
• and
• a memory, coupled to the processor, the memory storing a module comprising instructions for causing the processor to perform the steps of:
• (A) obtaining with the user interface device prescription information for palivizumab for a patient, the instructions causing the display device to display an electronic form dedicated to receiving the prescription information solely for palivizumab, wherein the prescription information comprises a plurality of elements, the electronic form comprising blocks for receiving via the user input device elements comprising (i) information identifying the patient and (ii) a prescription for an amount of palivizumab;
• (B) receiving with the user interface device patient clinical information, the instructions causing the display device to display an electronic form dedicated to receiving the patient clinical information relevant to palivizumab wherein the patient clinical information comprises a plurality of determinants which collectively assist in determining whether a patient is a good candidate for palivizumab and contribute to a basis for authorizing or denying coverage to said patient for palivizumab, the electronic form comprising at least five blocks for receiving via the user input device a corresponding at least five determinants from the group of determinants consisting of
• a gestational age of the patient,
• a weight of the patient,
• a categorical indication as to whether the patient has congenital heart disease,
• a categorical indication as to whether the patient has chronic respiratory disease arising in the perinatal period,
• a categorical indication as to whether the patient has a chronic pulmonary disease,
• a categorical indication as to whether the patient has a congenital anomaly of the respiratory system, and
• for at least one of said categorical indications, one or more additional determinants associated with the categorical indication;
• wherein at least one determinant is not a standardized code;
• (C) storing the prescription information and the patient clinical information in a non-transitory computer-readable medium;
• (D) requesting approval for the patient for palivizumab by sending the prescription information and the patient clinical information from the apparatus to a specialty 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 palivizumab, 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) displaying with the display device the coverage decision made by the pharmacy.