Automated prior authorization for genetic efficacy testing with presciption dispensation

A method for automating preauthorization of genetic efficacy testing with prescription dispensation, said method comprising the steps of:

• electronically receiving a coverage request for a medication from a pharmacy system;
• electronically querying a policy rules database to retrieve policy rules associated with said coverage request;
• electronically querying one or more EHR systems to retrieve patient data for a patient associated with said coverage request;
• automatically and electronically performing, by way of a prior authorization engine, a coverage decision analysis for said coverage request using said retrieved policy rules and said retrieved patient data;
• electronically providing a coverage decision for said coverage request in accordance with said coverage decision analysis;
• electronically determining that said medication for said coverage request is otherwise approved for coverage;
• electronically querying a testing availability database to determine that genetic efficacy testing is available for said medication;
• automatically and electronically generating an electronic approval of coverage decision for said medication;
• automatically and electronically generating an electronic prior authorization for genetic efficacy testing for said medication;
• electronically transmitting said approval of coverage decision with said prior authorization for genetic efficacy testing to said pharmacy system;
• and
• notifying said patient of said prior authorization with dispensation of said medication.

A system for automating preauthorization of genetic efficacy testing with prescription dispensation, said system comprising:

• a number of electronic health record (“EHR”) systems, each associated with one or more respective healthcare providers, wherein each of said number of EHR systems comprises patient data for a respective number of patients;
• one or more policy databases comprising policy rules for one or more respective payors;
• one or more testing availability databases comprising medications for which genetic efficacy testing is available;
• a number of pharmacy systems, each associated with a respective pharmacy;
• a pharmacy benefits manager (“PBM”) system associated with a PBM and said number of pharmacy systems;
• a laboratory information system (“LIS”) associated with a laboratory;
• one or more genetic sequencing machines in electronic communication with the LIS;
• and
• a prior authorization engine, located at the LIS, and comprising software instructions stored at one or more electronic storage devices, which when executed, configures one or more processors to:
• receive coverage requests for medicines from the PBM system as provided to the PBM from the number of pharmacy systems;
• query said one or more policy databases to retrieve policy rules associated with each respective one of said coverage requests;
• query said one or more EHR systems to retrieve patient data for patients associated with each respective one of said coverage requests;
• provide initial coverage decisions for each respective one of said coverage requests in accordance with said retrieved policy rules and said retrieved patient data for each respective one of said coverage request;
• where said initial coverage decisions indicate that associated medications are not otherwise approved for coverage provide a denial of coverage decision;
• where said initial coverage decisions indicate that associated medications are otherwise approved for coverage:
• query said one or more testing availability databases to determine if genetic efficacy testing is available for said associated medications;
• where said genetic efficacy testing is not available for said associated medications, automatically generate an approval of coverage decision;
• where such genetic efficacy testing is available for said associated medications, automatically generate said approval of coverage decision and a prior authorization for said available genetic efficacy testing, where said prior authorization includes a period of time or number of refills for said medication associated with said coverage decision in which said genetic efficacy testing must be performed;
• and
• transmit said approval or denial of coverage decisions, along with any prior authorization for genetic efficacy testing, to said PBM system and requesting ones of said number of pharmacy systems;
• receive requests for additional fills of said medications;
• determine if said approval of coverage decision was issued for said medications for which additional fills are requested, and whether said approval of coverage decision included said prior authorization for genetic efficacy testing, and if so:
• query said one or more EHR systems to determine if results of said genetic efficacy testing are present;
• and
• provide said approval of coverage decision for said additional fills of said associated medication where results of said genetic efficacy testing are found and indicate that said associated medication is not undereffective or ineffective for said respective patient;
• and
• provide said denial of coverage decision for said additional fills of said associated medication where results of said genetic efficacy testing are not found, or are found and indicate that said associated medication is undereffective or ineffective for said respective patient.