SYSTEM AND METHOD FOR IMPROVING PHARMACY CLAIM PAYMENT CAPABILITIES

摘要

The present invention provides improved systems and methods for enhancing pharmacy claim payment capabilities. In one example aspect the invention provides a method for determining whether to process a claim for a drug for a member, comprising the steps of receiving the claim for the drug subject to specific clinical edits, accessing criteria specific to the drug, evaluating the claim for the drug with regard to the criteria specific to the drug, and determining based on one or more of the criteria whether to process the claim.