Behind the Counter: Adventures in Dispensing. Episode III.

[Shalom]

See, this is where it pays to have a pharmacist who's looking out for your best interests, rather than the chain's. (Or, I should say, rather than just the chains; that's his job, after all.)

I've had patients taking, for example, synthroid, who needed a dose in between what is readily available. Patient had titrated out at 225mcg, which isn't commercially available, so they were getting a 200 and a 25, and paying 2 copays. I suggested to the doctor that they just give him the 112mcg and tell him to take two of them, and thereby get 60 tabs for one copay instead.

(Or, I had to go the other way recently. Patient on Concerta, needed 72mg, so the doctor wrote for 36mg, take 2 tabs daily, dispense #60. Insurance says they're only paying for 30 per fill. This means he's going to run out after only 15 days, and as a C-II you can't give a refill, so he needs to get a new prescription every 15 days now. I suggested he get a 54mg and an 18mg, adds up to the same 72mg, and yes he'll have 2 copays now, but at least he doesn't have to keep getting new Rxs every two weeks.)

[Sapphire Silk]

I've had patients taking, for example, synthroid, who needed a dose in between what is readily available. Patient had titrated out at 225mcg, which isn't commercially available, so they were getting a 200 and a 25, and paying 2 copays. I suggested to the doctor that they just give him the 112mcg and tell him to take two of them, and thereby get 60 tabs for one copay instead.

I actually write test questions for my nursing students around just this issue, with the same thing in mind: cost effective care

[dalesys]

... cost effective care

But... But... But... Da Ebil wants cost inflictive care!

[PuckLizardRN]

I am imagining a person chewing on an alcohol pad, then calling the MD to complain that not only do they not work, but they taste nasty and cause nausea and constipation.

[EricKei]

Puck - You're reminding me of an article I read yesterday about common comments on recipe blogs, specifically the ones that say things like "I changed almost all of your listed ingredients to [something else random - e.g., 'I didn't have beef, basil, or tomatoes, so I used tofu, curry powder and plums'] and the dish came out completely wrong! this recipe is horrible!"

[CorneliaMarieRocks]

Shalom, funny you should bring up the C-II issue...I have a question, I'm in GA & our pharmacy recently informed us that any 'script that has hydrocodone in it would be switching from C-III to C-II & that as of a certain date (Oct 6th I believe) any refills we had left would be null & void...I looked on the DEA's official site & it said somewhere on there that instead of having to do get a new script every month that your doctor could simply write 2 scripts & write on the second 'script "Do Not Fill Before Such & Such Date"...Question is, is that true? Can our dr do that?

[AccountingDrone]

Puck - You're reminding me of an article I read yesterday about common comments on recipe blogs, specifically the ones that say things like "I changed almost all of your listed ingredients to [something else random - e.g., 'I didn't have beef, basil, or tomatoes, so I used tofu, curry powder and plums'] and the dish came out completely wrong! this recipe is horrible!"

Well, I am going to rework the apple chili recipe by removing the added sugar, swapping out half the apples for diced pumpkin, using extra tart cooking apples and cubes of beef instead of ground bison .. and I still say it is not chili, it is a mock medieval meat pie filling.

[Argus]

comments on recipe blogs, specifically the ones that say things like "I changed almost all of your listed ingredients to [something else random

This Dilbert strip comes to mind: http://dilbert.com/strips/comic/1997-12-28/

[Shalom]

Shalom, funny you should bring up the C-II issue...I have a question, I'm in GA & our pharmacy recently informed us that any 'script that has hydrocodone in it would be switching from C-III to C-II & that as of a certain date (Oct 6th I believe) any refills we had left would be null & void...

Here's what Georgia's state board of pharmacy has to say about this. Basically, existing scripts with refills will continue to be refillable until six months after the date of the changeover; anything newly written after 10/6/14 will have no refills allowed.

I looked on the DEA's official site & it said somewhere on there that instead of having to do get a new script every month that your doctor could simply write 2 scripts & write on the second 'script "Do Not Fill Before Such & Such Date"...Question is, is that true? Can our dr do that?

Not sure. Give me a couple days to research that. Different states may have varying laws. I'm pretty sure New York law doesn't allow it, for the reason that in NY a C-II script must be filled by 30 days of the date written, and the "Do Not Fill Until" date on all but the first script is going to be past that. There's been a recent change in this law, but I don't remember which way they changed it...

(I've also seen doctors hand patients a stack of post-dated prescriptions for chronic stuff, one for each month until their next appointment. This I'm pretty sure is illegal, but I can't see how they'll get caught at it.)

[Sapphire Silk]

(I've also seen doctors hand patients a stack of post-dated prescriptions for chronic stuff, one for each month until their next appointment. This I'm pretty sure is illegal, but I can't see how they'll get caught at it.)

They get caught when a patient brings the wrong script to the pharmacy, and the pharmacist narcs to the Medical Board or the DEA. Or when a patient tries to fill more than one script at once, and goes all SC on the pharmacist, who gets pissed, and reports it to the Medical Board or the DEA.

That happened once to a doctor I know. He wrote some post dated scripts for Ritalin for a kid with ADHD so the mother wouldn't have to come to the office once a month. The mother tried to fill several scripts at once, and made such a scene when the pharmacist refused that the physician got in trouble with the DEA and almost lost his prescribing authority for controlled substances.

[CorneliaMarieRocks]

Ok, by the link you posted Shalom, this means that if I go in to my doctor this coming Monday (say for the sake of argument) then my doctor can write my Norco 'script as he always has, which is 1 written 'script with 1 refill allowed & the Pharmacy we use (U Save It which is only in GA) & because the 'script is dated before Oct 6th then that refill is still valid. But my mom who has an appointment ON Oct 6th couldn't get a 'script with 1 refill allowed, even though that one refill isn't going to last until April 8th '15 (in other words, if the dr. wrote her 'script the same as he does mine, the RPh would not consider the 1 refill allowed on her 'script valid?)

Am I understanding that correctly? Because frankly, because I have no insurance my co-pay is $121.00 bucks & then the meds are $65.00 so I can't be going to the dr. every single month to get a new 'script

[Shalom]

They get caught when a patient brings the wrong script to the pharmacy, and the pharmacist narcs to the Medical Board or the DEA. Or when a patient tries to fill more than one script at once, and goes all SC on the pharmacist, who gets pissed, and reports it to the Medical Board or the DEA.

OK, I stand corrected. I can't see how he'd be caught if he doesn't have patients who are assholes.

As a pharmacist, I'd simply refuse to fill a post-dated prescription, and tell them to come back on or after that date. They can get as SCy on me as they like, but where drugs are concerned I am the man with the power of No and I can make it stick. I wouldn't blow the doctor in to the DEA, though. He's acting in the best interest of his patient there. The second scenario shouldn't occur if the doctor knows who his patients are, and doesn't advance scripts to those who would abuse the privilege.

Ok, by the link you posted Shalom, this means that if I go in to my doctor this coming Monday (say for the sake of argument) then my doctor can write my Norco 'script as he always has, which is 1 written 'script with 1 refill allowed & the Pharmacy we use (U Save It which is only in GA) & because the 'script is dated before Oct 6th then that refill is still valid. But my mom who has an appointment ON Oct 6th couldn't get a 'script with 1 refill allowed, even though that one refill isn't going to last until April 8th '15 (in other words, if the dr. wrote her 'script the same as he does mine, the RPh would not consider the 1 refill allowed on her 'script valid?)

This is correct.

Just a caveat, though. Just because it's legal doesn't mean your pharmacist is going to want to do it, or even may not be able to, depending on how his software is configured. If his software vendor logs in at 11:59PM on 10/5 and simply disallows any refills on any hydrocodone product, there may just not be any way to refill that prescription. My own software, for example, has a checkbox marked Disallow Refills (or words to that effect) on each drug record, which is checked for C-II drugs (and in New York State, also for anabolic steroids and benzodiazepines, which are C-III and C-IV respectively), but I can't see any way for the program to disallow refills on only new scripts while yet allowing them on old ones; it's either allowed or it's not. On the other hand, that field is changeable by me, so he could temporarily uncheck the box, fill the refill, and then check it again. (Assuming they even know it's there; I'm probably the only one in my store that does.)

Talk to them before the date, if you think you'll be going in with scripts with refills before Monday. After that, of course, it's moot.

Am I understanding that correctly? Because frankly, because I have no insurance my co-pay is $121.00 bucks & then the meds are $65.00 so I can't be going to the dr. every single month to get a new 'script

If he's willing to write a script with a refill, he should be just as willing to write a second script and either post-date it, or (if your state allows) put "Do Not Fill Before" on it, without charging you for a second visit. (I'm assuming you don't behave like the patients in SapphireSilk's post.) Worst case, he can mail you, or your pharmacy, the second script in time for the date it's due. Offer him a stamp if he balks.

(Here's what the DEA has to say regarding "Do Not Fill Before". Executive summary: Doctor can give multiple prescriptions for up to a 90 day supply at one time. As mentioned, this doesn't work in NY, where I practice, because unfilled controlled substance prescriptions expire here 30 days from date written. I just did a quick read-through of the Georgia Board of Pharmacy rules, though, and I couldn't find anything about a date beyond which prescriptions can't be filled, other than the usual 6-month expiration found in Federal controlled-substance law. Must be a New York thing.)

Here's another link with a list of various state policies regarding CDS prescriptions.

[Portellia]

Perhaps you can set it up with your doctor to have the office send a new e-script every month or whatever when you call to ask for it?
So long as your office visits are frequent enough to adequately monitor your condition and s/he puts a note in your file that it's OK to send a monthly refill until X day, they might be able to do that.

[Sapphire Silk]

Perhaps you can set it up with your doctor to have the office send a new e-script every month or whatever when you call to ask for it?
So long as your office visits are frequent enough to adequately monitor your condition and s/he puts a note in your file that it's OK to send a monthly refill until X day, they might be able to do that.

That only works if state law allows escripts for Schedule II's. And the doctor still has to enter the system, IIRC, to send it.

And honestly, doctor's offices will have the lines tied up with that sort of thing.

I think what will happen is doctors will switch most patients to a Schedule III to avoid the whole mess. I see more prescriptions for Tylenol #3 coming along. And more abuse of heroin

[CorneliaMarieRocks]

Sorry to revive such an old thread, but I just thought I'd update

The way our dr. works it is, whenever one of us goes in to get new pain med 'scripts, he basically writes 2 'scripts, 1 to be filled that day & the other to be filled the next month but he does not post date or write 'Do not fill before' on it, he dates it for that day.

Then once we leave the dr's office, we turn in only the 1 'script that we are picking up that day at the pharmacy, the other 'script we hang onto until it's time for it to be filled (27 days from the last refill date)

Now, I'll probably get shat on for what I'm about to say but please hear me out before you pass judgement. Because I don't have insurance, if say, one month I get my 'script filled at U Save It (which is our regular pharmacy & an independent) & then let's say that when I go to turn in my second 'script so they can fill it on day 27, that they tell me they can only do a partial fill on it. I can then, instead of running the risk of not being able to get all my pills at once, I can take the 'script to Walmart & pay cash, plus Walmart's quite a bit cheaper, only reason I go to the Indie pharmacy is b/c they special order the yellow Qualitest Norcos specifically for us b/c they work the best for us.

Now, I don't do that on a regular basis so put down the pitchforks, I only do that if I am COMPLETELY out of my pain meds