Abstract: Systems and methods for overriding claim denials and approvals are provided that determine that a current claim will be denied and search the purchasing member's claim history for previously approved claims that match the current claim. If a matching claim is found and is dated within a certain predetermined window of time, the current claim is approved. Additionally, when it is determined that a current claim will be approved at a high tier level the member's claim history is searched for a previously approved claim that matches the current claim and a formulary crosswalk analysis is performed. If a matching claim with a lower tier level is found in the member's claim history or the crosswalk analysis determines that a lower tier level is available, the current claim is processed using the lower tier. Claims overridden are digitally stamped for reporting purposes and for subsequent claim matching.

Abstract: Systems and methods for proactively identifying impacts and making recommendations regarding modifications to a drug formulary are provided. In an embodiment, a proposed modification to a formulary is received. One or more data sources are accessed, and an impact of the proposed modification to the formulary is determined based on the one or more data sources. The impact of the proposed modification is then provided to a user prior to implementation of the proposed modification.

Abstract: Systems and methods for generating and managing a hybrid formulary for claims adjudication. In an embodiment, a plurality of source formulary components are received. Each of the plurality of source formulary components comprises one or more drug entries and/or one or more utilization management rules. A configuration is also received. The configuration comprises a plurality of component identifiers and one or more hierarchy rules. Each of the plurality of component identifiers identifies one of the plurality of source formulary components. The one or more hierarchy rules are applied to the identified source formulary components to generate a hybrid formulary. The hybrid formulary comprises a plurality of drug entries and/or one or more utilization management rules, which can be used for claims adjudications, reporting, or any other downstream formulary application.

Abstract: Systems and methods for proactively identifying impacts and making recommendations regarding modifications to a drug formulary are provided. In an embodiment, a proposed modification to a formulary is received. One or more data sources are accessed, and an impact of the proposed modification to the formulary is determined based on the one or more data sources. The impact of the proposed modification is then provided to a user prior to implementation of the proposed modification.

Abstract: Systems and methods for overriding claim denials and approvals are provided that determine that a current claim will be denied and search the purchasing member's claim history for previously approved claims that match the current claim. If a matching claim is found and is dated within a certain predetermined window of time, the current claim is approved. Additionally, when it is determined that a current claim will be approved at a high tier level the member's claim history is searched for a previously approved claim that matches the current claim and a formulary crosswalk analysis is performed. If a matching claim with a lower tier level is found in the member's claim history or the crosswalk analysis determines that a lower tier level is available, the current claim is processed using the lower tier. Claims overridden are digitally stamped for reporting purposes and for subsequent claim matching.

Abstract: A method of processing drug claims, by: (a) receiving a claim; (b) sorting the claim for processing by determining which processed drug list the claim belongs with; and then (c) processing the claim according to the particular processed drug list to which the claim belongs. A hierarchy of drug lists are used in a preferred order. If the drug is found on the first drug list, the system then moves directly to the processing stage. However, if the drug is not found on the first list, the system checks whether the drug is on the second drug list. If the drug is found on the second drug list, the system then moves directly to the processing stage, etc.

Abstract: A method of processing drug claims, by: (a) receiving a claim; (b) sorting the claim for processing by determining which processed drug list the claim belongs with; and then (c) processing the claim according to the particular processed drug list to which the claim belongs. A hierarchy of drug lists are used in a preferred order. If the drug is found on the first drug list, the system then moves directly to the processing stage. However, if the drug is not found on the first list, the system checks whether the drug is on the second drug list. If the drug is found on the second drug list, the system then moves directly to the processing stage etc.

Abstract: A method of operating a formulary and software therefore comprising a unique formulary maintenance tool are disclosed which allows for much greater participation of a PBM In the maintenance and upgrading of formularies. The method and software allow the PBM to create a wide range of useful and efficient proxies (“top down” operation) and not wait for organizations such as CMS or clients to define specific and limited drugs (“bottom up” operation). The system retains the ability to incorporate CMS- and client-defined proxies but also allows the PBM to create such proxies on its own from competent source information. It also includes sorting, navigation, comparison and communication capabilities which will result in significantly more efficient claim adjudication and system maintenance.