Method for providing consumer choice and equalizing pharmacy provider availability in prescription medication dispensing plans

Abstract

A method is disclosed whereby consumers enrolled in a prescription benefit plan can obtain prescription medication fulfillment at any participating pharmacy of their choice, regardless of whether the fulfillment is by a retail pharmacy or a mail order pharmacy, and whether the quantity of medication prescribed is for administration over a short period (acute care) or a prolonged period (maintenance). The plan of this invention operates by having the plan manager substantially equalize the financial effects of the discounts and services fees allowed to participating pharmacies such that both retail and mail order pharmacies are compensated in a manner which encourages them to accept all consumers and fill all prescriptions. Compensation is preferably adjusted periodically by the manager to retain pharmacy incentives. Consumers obtain choice of pharmacies, plan payers have pleased employees and members and pharmacies obtain income from the entire spectrum of consumers.

1 . A method for broadening persons' access to pharmacies for fulfillment of prescriptions under prescription benefit plans, which method comprises: 
 providing a prescription benefit plan managed by a benefit manager and subscribed to by at least one payer, under which a person affiliated with said payer may have a medical prescription filled at any participating pharmacy;    enrolling at least one participating pharmacy in said plan to provide fulfillment of said prescription upon request by said person and approval by said manager;    establishing a market price for a medication dispensed based on such prescription;    establishing a discounted amount of such market price with said discounted amount to be paid by said manager to said pharmacy for fulfillment of said prescription; and    establishing said discounted amount at a level such that participation in said plan is substantially equally attractive to any type of pharmacy;    whereby the choice of said person of which pharmacy to patronize for fulfillment of said prescription is not unduly influenced by financial considerations.    
     
     
         2 . A method as in  claim 1  wherein said participating pharmacy comprises a retail pharmacy or a mail order pharmacy.  
     
     
         3 . A method as in  claim 1  further comprising said payer paying to said manager in connection with said fulfillment of said prescription by said pharmacy a reimbursement amount sufficient to cover said discounted amount paid by said manager to said pharmacy.  
     
     
         4 . A method as in  claim 3  where said payer further pays to said manager an fee for said manager's service in managing said plan for fulfillment of said prescription for said person affiliated with said payer.  
     
     
         5 . A method as in  claim 1  wherein subscription by said payer to said plan is by contract with said manager.  
     
     
         6 . A method as in  claim 1  wherein enrollment by said pharmacy in said plan is by contract with said manager.  
     
     
         7 . A method as in  claim 1  wherein said market price for said medication is determined by reference to at least one public market price compilation regarding such medication.  
     
     
         8 . A method as in  claim 7  wherein said manager selects said public market price compilation on which to base said market price.  
     
     
         9 . A method as in  claim 8  wherein determination of said market place is determined by said manager by reference to a plurality of said public market price compilations.  
     
     
         10 . A method as in  claim 1  wherein at least one of said market price and said discounted amount is determined by at least one of the identity of the medication prescribed, the dosage of said medication prescribed and the quantity of dosage units prescribed.  
     
     
         11 . A method as in  claim 10  wherein determination is based on said quantity of dosage units prescribed.  
     
     
         12 . A method as in  claim 11  wherein said quantity of dosage units prescribed comprises not more than about one month's supply of said medication for said person.  
     
     
         13 . A method as in  claim 11  wherein said quantity of dosage units prescribed comprises more than about one month's supply of said medication for said person.  
     
     
         14 . A method as in  claim 13  wherein said quantity of dosage units prescribed comprises at least about two months' supply of said medication for said person.  
     
     
         15 . A method for broadening persons' access to pharmacies for fulfillment of prescriptions under prescription benefit plans, which method comprises: 
 providing a prescription benefit plan managed by a benefit manager and subscribed to by at least one payer, under which a person affiliated with said payer may have a medical prescription filled at any participating pharmacy;    enrolling at least one participating pharmacy in said plan to provide fulfillment of said prescription upon request by said person and approval by said manager;    establishing a market price for a medication dispensed based on such prescription;    establishing a discounted amount of such market price with said discounted amount to be paid by said manager to said pharmacy for fulfillment of said prescription;    establishing said discounted amount at a level such that participation in said plan is substantially equally attractive to any type of pharmacy;    conducting assessment of said participation of a pharmacy in said plan to determine performance of said pharmacy in comparison with other pharmacies also enrolled in said plan; and    adjusting said discounted amount paid to said pharmacy periodically in response to said assessment of said performance to provide incentive for good performance;    whereby the choice of said person of which pharmacy to patronize for fulfillment of said prescription is not unduly influenced by financial considerations and pharmacies enrolled are given incentive to provide good service to said person.    
     
     
         16 . A method as in  claim 15  wherein said participating pharmacy comprises a retail pharmacy or a mail order pharmacy.  
     
     
         17 . A method as in  claim 15  wherein adjusting said discounted amount in response to said assessment comprises truing up said discounted amount.  
     
     
         18 . A method as in  claim 17  wherein truing up said discounted amount comprises increasing said discounted amount for a pharmacy which has exceeded performance expectations during an assessment period and decreasing said discounted amount for a pharmacy which has fallen short of performance expectations during an assessment period.  
     
     
         19 . A method as in  claim 17  wherein said truing up is conducted periodically.  
     
     
         20 . A method as in  claim 15  further comprising said payer paying to said manager in connection with said fulfillment of said prescription by said pharmacy a reimbursement amount sufficient to cover said discounted amount paid by said manager to said pharmacy.  
     
     
         21 . A method as in  claim 20  where said payer further pays to said manager an fee for said manager's service in managing said plan for fulfillment of said prescription for said person affiliated with said payer.  
     
     
         22 . A method as in  claim 15  wherein subscription by said payer to said plan is by contract with said manager.  
     
     
         23 . A method as in  claim 15  wherein enrollment by said pharmacy in said plan is by contract with said manager.  
     
     
         24 . A method as in  claim 15  wherein said market price for said medication is determined by reference to at least one public market price compilation regarding such medication.  
     
     
         25 . A method as in  claim 24  wherein said manager selects said public market price compilation on which to base said market price.  
     
     
         26 . A method as in  claim 25  wherein determination of said market place is determined by said manager by reference to a plurality of said public market price compilations.  
     
     
         27 . A method as in  claim 15  wherein at least one of said market price and said discounted amount is determined by at least one of the identity of the medication prescribed, the dosage of said medication prescribed and the quantity of dosage units prescribed.  
     
     
         28 . A method as in  claim 27  wherein determination is based on said quantity of dosage units prescribed.  
     
     
         29 . A method as in  claim 28  wherein said quantity of dosage units prescribed comprises not more than about one month's supply of said medication for said person.  
     
     
         30 . A method as in  claim 28  wherein said quantity of dosage units prescribed comprises more than about one month's supply of said medication for said person.  
     
     
         31 . A method as in  claim 30  wherein said quantity of dosage units prescribed comprises at least about two months' supply of said medication for said person.  
     
     
         32 . A method for broadening persons' access to pharmacies for fulfillment of prescriptions under prescription benefit plans, which method comprises: 
 providing a prescription benefit plan managed by a benefit manager and subscribed to by at least one payer, under which a person affiliated with said payer may have a medical prescription filled at any pharmacy;    enrolling at least one pharmacy in said plan to provide fulfillment of said prescription upon request by said person and approval by said manager;    conducting assessment of said participation of a pharmacy in said plan to determine performance of said pharmacy in comparison with other pharmacies also enrolled in said plan; and    adjusting reimbursement paid to said pharmacy periodically in response to said assessment of said performance to provide incentive for good performance;    whereby the choice of said person of which pharmacy to patronize for fulfillment of said prescription is not unduly influenced by financial considerations and pharmacies enrolled are given incentive to provide good service to said person.    
     
     
         33 . A method as in  claim 32  wherein said participating pharmacy comprises a retail pharmacy or a mail order pharmacy.  
     
     
         34 . A method as in  claim 32  wherein adjusting said discounted amount in response to said assessment comprises truing up said discounted amount.  
     
     
         35 . A method as in  claim 34  wherein truing up said discounted amount comprises increasing said discounted amount for a pharmacy which has exceeded performance expectations during an assessment period and decreasing said discounted amount for a pharmacy which has fallen short of performance expectations during an assessment period.  
     
     
         36 . A method as in  claim 34  wherein said truing up is conducted periodically.  
     
     
         37 . A method as in  claim 32  wherein said assessment is conducted periodically.  
     
     
         38 . A method as in  claim 32  further comprising said payer paying to said manager in connection with said fulfillment of said prescription by said pharmacy an amount sufficient to cover said reimbursement paid by said manager to said pharmacy.  
     
     
         39 . A method as in  claim 38  where said payer further pays to said manager an fee for said manager's service in managing said plan for fulfillment of said prescription for said person affiliated with said payer.  
     
     
         40 . A method as in  claim 32  wherein subscription by said payer to said plan is by contract with said manager.  
     
     
         41 . A method as in  claim 32  wherein enrollment by said pharmacy in said plan is by contract with said manager.  
     
     
         42 . A method as in  claim 32  wherein said reimbursement for said medication is determined by reference to at least one public market price compilation regarding such medication.  
     
     
         43 . A method as in  claim 42  wherein said manager selects said public market price compilation on which to base said reimbursement.  
     
     
         44 . A method as in  claim 42  wherein determination of said reimbursement is determined by said manager by reference to a plurality of said public market price compilations.  
     
     
         45 . A method as in  claim 32  wherein said reimbursement is determined by at least one of the identity of the medication prescribed, the dosage of said medication prescribed and the quantity of dosage units prescribed.  
     
     
         46 . A method as in  claim 45  wherein determination is based on said quantity of dosage units prescribed.  
     
     
         47 . A method as in  claim 46  wherein said quantity of dosage units prescribed comprises not more than about one month's supply of said medication for said person.  
     
     
         48 . A method as in  claim 46  wherein said quantity of dosage units prescribed comprises more than about one month's supply of said medication for said person.  
     
     
         49 . A method as in  claim 47  wherein said quantity of dosage units prescribed comprises at least about two months' supply of said medication for said person.