GENERATING AND MANAGING A HYBRID FORMULARY

摘要

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.

主权项

1. A computer-implemented method of managing a hybrid formulary comprising, by at least one hardware processor:
receiving a configuration comprising a plurality of source identifiers and one or more hierarchy rules, wherein the plurality of source identifiers comprise a source identifier that identifies a first source formulary and a source identifier that identifies a second source formulary, wherein the second source formulary is different than the first source formulary, wherein each of the first source formulary and the second source formulary comprises a plurality of components, and wherein each of the plurality of components of both the first source formulary and the second source formulary comprises at least one of one or more drug entries, one or more tiers, and one or more utilization management rules; and generating a hybrid formulary by combining one or more of the plurality of components of the first source formulary with one or more of the plurality of components of the second source formulary, while applying the one or more hierarchy rules to resolve at least one conflict between one or more of the plurality of components of the first source formulary and one or more of the plurality of components of the second source formulary.