1 paper C2, bill insurance half, charge cash half, what about DEA?

[HelpfulPharmer1]

Folks, please provide law reference because this is confusing here. We will have people arguing and practicing both ways, the important key is: what does the law say?

Case: Script written for 60 pills of C2 med, Norco 5.
State insurance pays only 45 pills.
Patient willing to pay 15 pills with own money (credit card or cash).
Possible solutions:
Way number 1: do 1 billing only: pick 1: insurance or cash. Done with script.
Way number 2: do 2 billings: bill insurance 45 pills, then, retype the script, charge cash 15 pills, all same day, same visit. In the mind of some pharmacists, this same day, same visit constitutes 1 dispensing event.

Many managers I talked with said: 1 paper of C2, 1 billing: either all with insurance or all without insurance, no splitting. Reason: once the script is billed with insurance for some pills, the script is done. Action of "re-typing the script" to fill the rest of quantity would be considered as "refill of C2", which is not allowed.

This case is at chain pharmacy with all quantities available in store so we can not use the reason of "partial fill" as in "I filled some I had, ordered some more, then completed the script within 72 hours."
Even if we try "partial fill", it would not work because:

Suppose we try to follow the law of doing "partial fill":
Step 1: First fill of 45 pills with insurance:
the transaction will have zero copay at selling time because corporate policy is zero copay for partial, this suggest insurance is not billed.

Step 2: Order med, med comes in next day.

Step 3: Second fill of 15 pills, now, at this step, the software will try to really bill insurance for 60 pills and insurance will reject saying insurance pays only 45 pills, so we are back to the start.
Therefore, we can not partial fill and still bill 2 ways.

With the law I have seen now, 1 billing is the legal way to do.

Just trying to help patient that is already in pain so they don't have to go back to doctor for new script.

Any DEA written statements or previous written cases that allows 2 billings for 1 script: insurance and cash? same day, same visit, same 1 pickup.

Thank you very much for your helpful thoughts.

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[Sine Cura]

Weissman California law book, eight edition (2013-2015), p. 315

D. How Might a Situation Be Handled Whereby A Patient Brings In A Schedule II Prescription For a 60 Day Supply And Insurance Will Pay For Only 30 Days?

"The pharmacist may dispense a 30 day supply and bill the insurance carrier accordingly and dispense another 30 day supply in a second container to be paid for by the patient. The amount of drug supply may be divided in any number of ways, as long as there are separate labels for each container and the total does not exceed the amount written for on the prescription."

Source: http://www.pharmacy.ca.gov/publications/01_jul_script.pdf

This is California though and not explicitly stated in state law. I do not recall the DEA issuing guidance w.r.t. to insurance limits but obviously many people consider splitting a script an act of partial filling, which is not allowed in the situation where the full amount can be supplied. Commonly used pharmacy software systems (AFAIK) provide no provision for partial fills for CIIs in any case.

 

[BenJammin]

Partial filling of C2s is the only portion of the Code of Federal Regulations that specifically states situations in which you may partial fill. 1306.13 states The partial filling of a prescription for a controlled substance listed in Schedule II is permissible if the pharmacist is unable to supply the full quantity called for in a written or emergency oral prescription and he makes a notation of the quantity supplied on the face of the written prescription, written record of the emergency oral prescription, or in the electronic prescription record. The remaining portion of the prescription may be filled within 72 hours of the first partial filling; however, if the remaining portion is not or cannot be filled within the 72-hour period, the pharmacist shall notify the prescribing individual practitioner. No further quantity may be supplied beyond 72 hours without a new prescription.

In your scenario, what the insurance covers is irrelevant. It is written for 60 tablets and you have it in stock. It's either 60 or less as one fill. You can give them 45 but they forfeit the rest because it would be an impermissible partial fill.

 

[owlegrad]

Commonly used pharmacy software systems (AFAIK) provide no provision for partial fills for CIIs in any case.

CVS system would allow you to type a written quantity of 60 and a dispensed quantity of 45. Once that 45 has been verified the system will allow you to fill the remaining 15 on file. Like you said, completely legal.

What is not legal is giving the same physical prescription two different prescription numbers (sorry I don't have the reference statute handy). I would not be willing to do that.

 

[PharmacistReb]

I worked in an independent for several years and had a McKesson system that would allow me to dispense 45 on insurance and then dispense the remaining 15 all on the same prescription number for CII's

 

[SClENCE]

Billing 45 with insurance and 15 for cash is legal if it can be done in the same fill. If your system doesn't have a feature that allows you to do this then you have to choose cash or insurance. You cannot legally do a partial fill or two separate fills on the prescription even if it's the same day and same prescription number. I know CVS does not have this feature and honestly don't know of anybody that does so to me it seems like it's one or the other.

Here's my question. What if this situation occurs with, say, Tramadol. If the doctors writes 30 tablets for 30 days supply, and they can only afford 15 tablets, do they have to wait for 15 days to get the remainder of the script or can they pick up the remaining 15 at any time since the script was written for a 30 day supply to begin with? As stupid as it sounds my understanding is that they would have to wait.

 

[SClENCE]

CVS system would allow you to type a written quantity of 60 and a dispensed quantity of 45. Once that 45 has been verified the system will allow you to fill the remaining 15 on file. Like you said, completely legal.

What is not legal is giving the same physical prescription two different prescription numbers (sorry I don't have the reference statute handy). I would not be willing to do that.

This is contrary to what I have been told. Maybe I am wrong, or maybe my state just has different laws?

 

[Estrace]

Billing 45 with insurance and 15 for cash is legal if it can be done in the same fill. If your system doesn't have a feature that allows you to do this then you have to choose cash or insurance. You cannot legally do a partial fill or two separate fills on the prescription even if it's the same day and same prescription number. I know CVS does not have this feature and honestly don't know of anybody that does so to me it seems like it's one or the other.

Here's my question. What if this situation occurs with, say, Tramadol. If the doctors writes 30 tablets for 30 days supply, and they can only afford 15 tablets, do they have to wait for 15 days to get the remainder of the script or can they pick up the remaining 15 at any time since the script was written for a 30 day supply to begin with? As stupid as it sounds my understanding is that they would have to wait.

With the tramadol question, I always make them wait. What difference does it make anyway? You have a 15 days supply, so you can pick up the rest after you run out assuming you're not doing anything illegal with the med.

I will never assign two RX numbers on a CII script.

 

[Estrace]

CVS system would allow you to type a written quantity of 60 and a dispensed quantity of 45. Once that 45 has been verified the system will allow you to fill the remaining 15 on file. Like you said, completely legal.

What is not legal is giving the same physical prescription two different prescription numbers (sorry I don't have the reference statute handy). I would not be willing to do that.

I have never tried this on a CII script, but I will definitely do it if our system allows it.

 

[PharmacistReb]

Billing 45 with insurance and 15 for cash is legal if it can be done in the same fill. If your system doesn't have a feature that allows you to do this then you have to choose cash or insurance. You cannot legally do a partial fill or two separate fills on the prescription even if it's the same day and same prescription number. I know CVS does not have this feature and honestly don't know of anybody that does so to me it seems like it's one or the other.

Here's my question. What if this situation occurs with, say, Tramadol. If the doctors writes 30 tablets for 30 days supply, and they can only afford 15 tablets, do they have to wait for 15 days to get the remainder of the script or can they pick up the remaining 15 at any time since the script was written for a 30 day supply to begin with? As stupid as it sounds my understanding is that they would have to wait.

If it's written as a 30-day supply, you can dispense all of 30 days or you can do 10 one day and 20 the next. What federal law would have them wait since partial filling of controlled non-CII's is not illegal?

I have been in retail and I've had discussions with Board inspectors numerous times -- all of these type things are small potatoes. These guys are looking primarily for people who are abusing their stock, not managing their stock or reconciling their numbers, or selling their stock. If you make it a practice to do things like partial filling a CII, then they will tell you to start following the law. But helping a legitimate hurting patient out by filling a scrip under cash and insurance is not going to get you in trouble with a BOP.

This may be something that you guys in the corporate arena deal with from district managers. But as far the legality, this is not something that's going to cause some major red flag to appear with a BOP and cause you to have your license suspended.

 

[owlegrad]

I know CVS does not have this feature...

You are wrong. I already explained above how to do it. I have done it and seen it done, so I know it can be done in the system. I don't really understand why you would claim CVS system doesn't allow it when I explained it does, lol.

This is contrary to what I have been told. Maybe I am wrong, or maybe my state just has different laws?

Could be, once you take law class you should have a good idea of what your state allows. You will probably find out a lot of what you have been told by practicing pharmacists is not factually correct. And like you can see above, there is not always a consensus on what is legal. Ben thinks it is illegal based on the law covering partial fills, the authors of the law book Sine quoted disagree.

 

[trailerpark]

My state doesn't allow you to cash out state insurance. So I would only fill it for what the insurance allows. I never spend more time on people with state insurance. I go the extra mile for people who work and pay taxes and are responsible.

 

[SClENCE]

You are wrong. I already explained above how to do it. I have done it and seen it done, so I know it can be done in the system. I don't really understand why you would claim CVS system doesn't allow it when I explained it does, lol.



Could be, once you take law class you should have a good idea of what your state allows. You will probably find out a lot of what you have been told by practicing pharmacists is not factually correct. And like you can see above, there is not always a consensus on what is legal. Ben thinks it is illegal based on the law covering partial fills, the authors of the law book Sine quoted disagree.

But in the example you used, the medication would be in two separate vials wouldn't it? This is would be considered a partial fill then, one lablel as 45 tablets through insurance and one label as 15 for cash. Same Rx number but two fills right? I could be completely wrong but this is the only way I know of doing it. Unless you can set up the COB for it to bill cash and insurance for the same fill and have 60 tablets filled in 1 label but I don't think this is what you are referring to nor do I think it's possible.

 

[SClENCE]

If it's written as a 30-day supply, you can dispense all of 30 days or you can do 10 one day and 20 the next. What federal law would have them wait since partial filling of controlled non-CII's is not illegal?

Partial filling a non CII is obviously legal, but from my understanding you cannot refill it unless they have a 2 day supply or less. If you just gave them a 10 day supply, and then gave them the rest the next day, you would obviously be breaking this rule. My question is that does this rule even apply in this situation since the script was written for all 30 days to dispensed at once in the first place? I'm not trying to debate yes/no or what is "best judgement", I'm simply asking if it is legal.

 

[Carboxide]

My question is that does this rule even apply in this situation since the script was written for all 30 days to dispensed at once in the first place? I'm not trying to debate yes/no or what is "best judgement", I'm simply asking if it is legal.

NO - it is NOT legal. If you use 2 Rx numbers, it is obviously illegal. If you use the same one, then the second dispensing is technically a refill. One bottle. One Rx label. That is all you can do.

 

[SClENCE]

NO - it is NOT legal. If you use 2 Rx numbers, it is obviously illegal. If you use the same one, then the second dispensing is technically a refill. One bottle. One Rx label. That is all you can do.

You don't have to use 2 Rx numbers to partial a prescription and nobody here is suggesting this. If the second dispensing is considered a refill then if you dispense 15 Tramadol on a 30 day supply quantity #30 you cannot dispense the remaining for 13 days, and you cannot split a CII between insurance and cash because you would be "refilling" the CII when you fill the remaining tablets for cash. This answers my question!

 

[Ackj]

Is this going to be a one time thing, or recurring monthly? Also would be helpful to know the days supply here/exact insurance rejection. Is it #60, 1bid, so 30 days, but the insurance limits #45 per 30 days? If they will allow #45 as a 22 day supply, you may be able to just get a new rx every 22 days.

Fill the #45 through insurance today, and contact prescriber for prior auth so maybe the insurance will allow #60. If they won't approve it, have the prescriber write 2 Rx every month, one for the #45 and one for the #15. They will have to be filled on separate days in accordance to NY 7 day law.

 

[Aznfarmerboi]

I think this is more of a state than a federal thing.

I too have contacted my state board of pharmacy. This is all legal... as long as it is under the same RX number.

In fact, if you read most laws clearly, it has more to do with qty dispensed versus day supplies... than whether it is a refill/partial fill.

 

[owlegrad]

But in the example you used, the medication would be in two separate vials wouldn't it? This is would be considered a partial fill then, one lablel as 45 tablets through insurance and one label as 15 for cash. Same Rx number but two fills right? I could be completely wrong but this is the only way I know of doing it. Unless you can set up the COB for it to bill cash and insurance for the same fill and have 60 tablets filled in 1 label but I don't think this is what you are referring to nor do I think it's possible.

Ahh yes I see what you mean. Yes in my example it would be two bottles with two labels.

 

[zelman]

You are wrong. I already explained above how to do it. I have done it and seen it done, so I know it can be done in the system. I don't really understand why you would claim CVS system doesn't allow it when I explained it does, lol.

That feature has been blocked in Massachusetts for years. Are you sure it still works in your state?

In MA, what the OP is suggesting is not allowed. C2 is 1 Rx = 1 fill.

For non-c2 things like RX for ambien #30 when insurance pays for #10 per month, I always bill #10 and #20 both as 30 day supplies on the same day. It's much easier to keep track of appropriate usage that way.[/QUOTE]

 

[owlegrad]

That feature has been blocked in Massachusetts for years. Are you sure it still works in your state?

It has been a while since I have done it so I can't be 100% sure.

 

[wagrxm2000]

Wag system will not allow refilling a c2.

Just tell the person to go elsewhere, problem solved.

 

[SClENCE]

This situation usually happens for patients on medicaid who take Adderall bid. Medicaid only covers 30 every 22 days.

 

[Sine Cura]

Well the patient always has the option for Adderall XR +/- Adderall IR

As someone said above I wouldn't go the extra mile for CIIs or Medicaid patients, so especially not for CIIs billed through Medicaid. I do give people options that don't clearly run afoul of CFR or state law (for example in AZ outpatient CII scripts have to be by themselves on the prescription pad, but I see quite a few California scripts with CII + other crap and even multiple CIIs even though these ******* doctors with CA and AZ licenses should know better, so I tell the patient they can go drive 20 miles to California or get the doctor to fix their mistake) but it's their choice to take my advice or go somewhere else.

Where the law is unambiguous, why should I even bother accommodating doctors who should know better because the patient might be inconvenienced?

 

[PharmacistReb]

"Partial filling a non CII is obviously legal, but from my understanding you cannot refill it unless they have a 2 day supply or less. If you just gave them a 10 day supply, and then gave them the rest the next day, you would obviously be breaking this rule."

Please copy and paste the specific statute with which you're referring because I don't know what you're referencing with the 2 day supply or less.

 

[SClENCE]

"Partial filling a non CII is obviously legal, but from my understanding you cannot refill it unless they have a 2 day supply or less. If you just gave them a 10 day supply, and then gave them the rest the next day, you would obviously be breaking this rule."

Please copy and paste the specific statute with which you're referring because I don't know what you're referencing with the 2 day supply or less.

There was a notice sent to every CVS stating this within the last month or two. Not sure if it's CVS policy or federal law but I'm pretty sure it was law.

 

[zelman]

There was a notice sent to every CVS stating this within the last month or two. Not sure if it's CVS policy or federal law but I'm pretty sure it was law.

That was (a portion of) a new policy.

 

[DASicari]

I think that was more for OOS situations. In CA, we are allowed to partial fill if we don't have it all in stock, but the remainder must be dispensed within 72 hours.

 

[Sine Cura]

CVS now has a 2-day early policy for controlled substances, where any fills earlier than 2 days must be approved by the prescriber and must be documented on the hard copy and in RxConnect, and only under "extenuating circumstances." Stores in certain states will see an RxConnect enhancement to support this policy based on time from point of sale.

 

[mgarph]

I know in the past as least the cvs system would allow it and I used to do it 45 on ins, 15 on cash, etc if done same day/one pickup but was told eventually by my manager or DM that we could no longer do it. Really no reason to risk it, just tell the patient to get 2 rx's and do one on ins and one cash

 

[BidingMyTime]

To the OP, the way I understand the law, that would not be legal. In situations like this, I will explain to the patient (or the doctor) that the patient needs 2 separate prescriptions with separate directions, something like Morphine 15mg qam & every other night #45 + Morphine 15mg every other night #15 (or has been mentioned, if the ins allows, run as a 22 day supply, every 22 days for the pt.

Here's my question. What if this situation occurs with, say, Tramadol. If the doctors writes 30 tablets for 30 days supply, and they can only afford 15 tablets, do they have to wait for 15 days to get the remainder of the script or can they pick up the remaining 15 at any time since the script was written for a 30 day supply to begin with? As stupid as it sounds my understanding is that they would have to wait.

Probably depends on the state. In IL, this is completely legal, and yes I would do it (as long as they are picking up at the same time.) What I won't do is refill the RX 4 hours after the patient bought the last one, because he suddenly "got paid." Um yeah.......obviously pharmacist discretion still needs to be used in filling a prescription, even if its strictly legal to do so.