Patent ID: 8457992

Claim:
A computer implemented method for determining compliance with contracted pharmacy reimbursement rates, comprising: storing in a computer memory pharmacy reimbursement contract information, the pharmacy reimbursement contract information being comprised of information regarding a plurality of contracts between a payor and a pharmaceutical product provider (“PPP”); receiving, via an electronic communications network, and storing in a computer memory a plurality of claims, each claim being comprised of claim information; comparing, via a computer processor, one or more of the plurality of received claims with at least one of the plurality of contracts by: identifying, via a computer processor, one or more of the plurality of contracts having pharmaceutical reimbursement contract information that is common with one or more of the received claims; if only one contract is identified, then associating the one contract with one or more of the received claims; storing in the computer memory an indication of the association of the one identified contract with one or more of the received claims; receiving, via the electronic communications network, pharmaceutical product information including a price of the pharmaceutical product; determining, by the computer processor, for each of the received claims and associated contract, a contracted claim amount, wherein the contracted claim amount is determined according to the terms of the contract and the pharmaceutical product information; determining, by the computer processor, whether the claim amount is different than the contracted claim amount; determining, by the computer processor, for each of the received claims and associated contract, if the received claim is a maximum allowable cost (MAC) exception; a. if the claim is a MAC exception, determining the MAC exception value, the MAC exception value being the greater of the difference between: i. the MAC rate for the received claim and the pharmaceutical product revenue; ii. the federal upper limit (FUL) for the pharmaceutical product and the pharmaceutical product revenue; and iii. the actual profit for the claim and a predetermined minimum value, the actual profit being the difference between the pharmaceutical product revenue and the pharmaceutical product acquisition cost; and b. storing in a computer memory an indication of the MAC exception value of the received claim and associated contract transmitting an indication of the difference between the claim amount and the contracted claim amount to the pharmaceutical product provider.