CII "partial" filling scenario?

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padfoot84sb

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I have seen this scenario play out in my pharmacy a few times lately and I wanted to see everyone's opinion on how to handle this?

I work for Rite Aid pharmacy in PA as an intern. We had a patient come to the pharmacy with a CII Rx for Vyvanse 30 mg #30 i qd. The patient wanted to just pay cash for 10 capsules now and then in a few days come back and get the other 20 when he could get more money to pay for them. My pharmacist told me that we could only fill for the 10 and then the patient would have to get a new Rx since dispensing the other 20 would be a "refill" in the system because we partially filled the Rx. I know the law states that if you partial fill a CII that you have to complete the remaining amount within I think 72 hours?

My questions are, if we dispensed 10 now does the patient need a new Rx to get another 20? Or can the patient come back within 72 hours to get the remaining amount and everything is fine? If the patient had ins (which he doesnt in this example) would it make a difference in filling the remaining quantity?

Any clarification on this issue would be really helpful so that I know how to handle this situation in the future! Thanks!
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From my understanding, the patient loses the remaining 20#. The 72 hour rule was put into effect for partial filling due to not enough stock and the need to order drug (so the patient wouldn't be w/o over a weekend or something for example) This pt is basically requesting a reduced quantity which voids the remaining amount.

Also, it really doesn't matter what "the system" says it should all be documented on the hard copy. If you did want to dispense only 10 out of 20 (for a different legal situation), in Nextgen you'd enter qty written as "30" and dispensed at "10" so the label would save "20 units remaining". There is nothing about refills. Or could could partial fill it for 10 using the little radio button and nextgen would pro-rate the price for a customer paying cash (it will return at price of 0 if using the rite aid savings card, so be careful with watching hundreds of $ walk). Then it would say "partial qty 10 of 30" on the label. Either way is fine
 
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Im not sure I would dispense a partial at a pt's request, unless of course they were someone that comes to us pretty regularly and we know what is going on with them. With that being said, if we only have a partial stock we fill partials all the time, so long as they come back to get the remainder within 72 hours.
As far as I know, the law doesn't specifically say that the partial has to be due to stocking issues, so I think legally you could dispense a partial at the pt's request, so long as they picked up the remainder within 72 hours.

Just as stated above, you can always put in the quantity as 30 and dispensed amount as 10, and then the computer will show 20 remaining and not a refill.
 
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kvl1027 said:
Im not sure I would dispense a partial at a pt's request, unless of course they were someone that comes to us pretty regularly and we know what is going on with them. With that being said, if we only have a partial stock we fill partials all the time, so long as they come back to get the remainder within 72 hours.
As far as I know, the law doesn't specifically say that the partial has to be due to stocking issues, so I think legally you could dispense a partial at the pt's request, so long as they picked up the remainder within 72 hours.

Just as stated above, you can always put in the quantity as 30 and dispensed amount as 10, and then the computer will show 20 remaining and not a refill.
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I have to agree with this. No real advantage in doing this and all kinds of possible trouble down the road. Customer comes in a day late and wants to raise a stink about it, Patient comes back 71.5 hours later and you don't have the quantity in stock, floater comes through the store on that day and thinks the patient automatically lost the remaining, etc...

Just opening yourself up to all kinds of trouble. Better to just tell them all-or-nothing (or lose the remaining), except for out of stocks of course.
 
kvl1027 said:
As far as I know, the law doesn't specifically say that the partial has to be due to stocking issues, so I think legally you could dispense a partial at the pt's request, so long as they picked up the remainder within 72 hours.
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Partial fillings of CIIs at the patients' request is legal only in two scenarios: if the patient is a 1) LTCF pt or 2) has a documented terminal illness.
 
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I don't bother with C-2 partials because it becomes a nightmare. It is legal to partial fill and the patient can get the remainder within the 72 hour window, but the logistics of it is hard. We get our C-2s on Friday and we know what we will receive by Tuesday afternoon. If the people can wait, we'll OOS it and fill it when we receive it on Friday.
 
c2s are a pain. our locked cabinet is overstuffed with unnecessary paperwork instead of oxycodone. sigh. i mean high 5!
 
I generally would not do a CII partial at the patients request (it just sounds like they are going to sell the first 10, to get money to buy the next 20.) Granted there could be an extenuating circumstance that I would consider it, but it would have to be a very good verifiable reason (like maybe their medicine was destroyed in a house fire, and their insurance wouldn't do an override, and they were going to buy enough until their insurance went through and their dr was say at the Mayo clinic 5 hrs away) But it most cases, it would be quite easy for the pt to get a new prescription from the doctor, so that is what I would tell them to do....
 
If you partial a C-II for any other reason than you the pharmacy not having the full amount in stock, then they the customer lose the entire balance of the prescription. If they can afford 10 out of 30 only, and you had a full 30, then they are not to get the remaining 20.
 
Music Man said:
Partial fillings of CIIs at the patients' request is legal only in two scenarios: if the patient is a 1) LTCF pt or 2) has a documented terminal illness.
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This is true. Also pharmacists are allowed to partial fill if they don't have the full quantity. see http://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_13.htm

"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."

So no I don't think it is legal to do to 2 fills off the same prescription if you have the full amount in stock. Because your inventory records will clearly show that you do.
 
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Also the verbage about a documented terminal illness is pretty specific and it says that if there is no documented terminal illness then partial filling a cII is in violation of the controlled substances act.
 
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MackandBlues said:
Also the verbage about a documented terminal illness is pretty specific and it says that if there is no documented terminal illness then partial filling a cII is in violation of the controlled substances act.
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Believe this only applies if the patient wants to fill the quantity prescribed in multiple partial fills. A patient can still get a partial fill at their request but lose the remainder of the prescription.
 
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law is pretty crystal clear here - you can do partial fills 1. LTCF 2. Terminal Illness 3. You don't have enough in stock and you can fill the remainder if you get it is less than 72 hours

This is often a practice exam question I have seen - if a patient requests a partial fill - they HAVE to get a new Rx for the remainder.
 
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Sorry to go a little off topic, but what about giving loaners for controlled medications. Let's say for example, pt comes in and wants a few pills of clonazepam to hold them off while waiting for refill authorization (and they have a hx in our system for this medication). Should I loan?
 
MedAffairer said:
Sorry to go a little off topic, but what about giving loaners for controlled medications. Let's say for example, pt comes in and wants a few pills of clonazepam to hold them off while waiting for refill authorization (and they have a hx in our system for this medication). Should I loan?
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Being a controlled substance is irrelevant. It's dispensing without authorization according to the law.
 
MedAffairer said:
It's against the law to loan bp, cholesterol, diabetic medicine, etc without authorization.. :cool:
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No it is not. Please show me where that is written. It would unethical and against the oath you take when you become a pharmacist. If you reasonably expect the physician to refill the medication, you are morally obligated and not legally prevented from advancing him or her a few pills in anticipation of the prescriber's authorization.
 
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You'll have to look up your state's pharmacy laws. For example, Florida does actually allow up to a 72 hour supply of maintenance drugs excluding CIIs. It doesn't say you can't do CIII-V, but in practice we don't do them, particularly in light of the current narcotics diversion problem in Florida.

465.0275 Emergency prescription refill.—In the event a pharmacist receives a request for a prescription refill and the pharmacist is unable to readily obtain refill authorization from the prescriber, the pharmacist may dispense a one-time emergency refill of up to a 72-hour supply of the prescribed medication, with the exception of those areas or counties included in an emergency order or proclamation of a state of emergency declared by the Governor, in which the executive order may authorize the pharmacist to dispense up to a 30-day supply, providing that:
(1) The prescription is not for a medicinal drug listed in Schedule II appearing in chapter 893.
(2) The medication is essential to the maintenance of life or to the continuation of therapy in a chronic condition.
(3) In the pharmacist’s professional judgment, the interruption of therapy might reasonably produce undesirable health consequences or may cause physical or mental discomfort.
(4) The dispensing pharmacist creates a written order containing all of the prescription information required by this chapter and chapters 499 and 893 and signs that order.
(5) The dispensing pharmacist notifies the prescriber of the emergency dispensing within a reasonable time after such dispensing.
 
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Old Timer said:
Please document this claim, it is false....
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Since you clearly don't understand how laws work, let me explain it to you. Laws will either tell you what is or what isn't permitted. The laws in my state say that prescription medication shall be dispensed pursuant to a verbal or written order. If there are no refills remaining on a 30 day supply then giving enough to last 31 is a violation of that law.
 
owlegrad said:
Yes please show me this law that makes loans illegal. I just love all the laws people know that are not on any books...
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I just love how you think that things must be explicitly be labeled as illegal for it to be illegal. Violation of legal activites oh that can't be....gulp....illegal. Nice one, genius.
 
BenJammin said:
Since you clearly don't understand how laws work, let me explain it to you. Laws will either tell you what is or what isn't permitted. The laws in my state say that prescription medication shall be dispensed pursuant to a verbal or written order. If there are no refills remaining on a 30 day supply then giving enough to last 31 is a violation of that law.
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Of course I will be happy to eat crow as soon as you produce said law...
 
owlegrad said:
Of course I will be happy to eat crow as soon as you produce said law...
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You're such a joke.

So pharmacists are allowed to dispense which Texas defines as to prepare, package, compound, or label, in the course of professional practice, a prescription drug or device for delivery to an ultimate user or the user's agent under a practitioner's lawful order. Oklahoma says that it is illegal to possess dangerous drugs without a valid prescription or a valid license to possess such drugs and dangerous drugs are defined as

8. “Dangerous drug”, “legend drug”, “prescription drug” or “Rx Only” means a
drug which:
a. under federal law, is required, prior to being dispensed or delivered, to
be labeled with one of the following statements:
(1) "Caution: Federal law prohibits dispensing without
prescription",
(2) "Caution: Federal law restricts this drug to use by or on the
order of a licensed veterinarian", or
(3) “Rx Only”, or
b. is required by any applicable federal or state law or regulation to be
dispensed on prescription only or is restricted to use by licensed
practitioners only;
9. “Dispense” or “dispensing” means the
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Start eating.
 
BenJammin said:
You're such a joke.

So pharmacists are allowed to dispense which Texas defines as to prepare, package, compound, or label, in the course of professional practice, a prescription drug or device for delivery to an ultimate user or the user's agent under a practitioner's lawful order. Oklahoma says that it is illegal to possess dangerous drugs without a valid prescription or a valid license to possess such drugs and dangerous drugs are defined as



Start eating.
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Well I'm not licensed in Texas but I found the law for you anyway:

http://www.statutes.legis.state.tx.us/Docs/OC/htm/OC.562.htm#562.054

Sec. 562.054. EMERGENCY REFILLS. (a) A pharmacist may exercise the pharmacist's professional judgment in refilling a prescription for a prescription drug, other than a controlled substance listed in Schedule II as established by the commissioner of state health services under Chapter 481, Health and Safety Code, without the authorization of the prescribing practitioner if:

(1) failure to refill the prescription might result in an interruption of a therapeutic regimen or create patient suffering;

(2) either:

(A) a natural or manmade disaster has occurred that prohibits the pharmacist from being able to contact the practitioner; or

(B) the pharmacist is unable to contact the practitioner after reasonable effort;

(3) the quantity of prescription drug dispensed does not exceed a 72-hour supply;

(4) the pharmacist informs the patient or the patient's agent at the time of dispensing that the refill is being provided without the practitioner's authorization and that authorization of the practitioner is required for a future refill; and

(5) the pharmacist informs the practitioner of the emergency refill at the earliest reasonable time.

(b) Notwithstanding Subsection (a), in the event of a natural or manmade disaster, a pharmacist may dispense not more than a 30-day supply of a prescription drug, other than a controlled substance listed in Schedule II as established by the commissioner of state health services under Chapter 481, Health and Safety Code, without the authorization of the prescribing practitioner if:

(1) failure to refill the prescription might result in an interruption of a therapeutic regimen or create patient suffering;

(2) the natural or manmade disaster prohibits the pharmacist from being able to contact the practitioner;

(3) the governor has declared a state of disaster under Chapter 418, Government Code; and

(4) the board, through the executive director, has notified pharmacies in this state that pharmacists may dispense up to a 30-day supply of a prescription drug.

(c) The prescribing practitioner is not liable for an act or omission by a pharmacist in dispensing a prescription drug under Subsection (b).
 
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BenJammin said:
You're such a joke.

So pharmacists are allowed to dispense which Texas defines as to prepare, package, compound, or label, in the course of professional practice, a prescription drug or device for delivery to an ultimate user or the user's agent under a practitioner's lawful order. Oklahoma says that it is illegal to possess dangerous drugs without a valid prescription or a valid license to possess such drugs and dangerous drugs are defined as



Start eating.
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You're the joke, you don't even know the law of your own state. How do practice pharmacy without knowing the law? I guess you just make them up to suit whatever you want.
 
owlegrad said:
You're the joke, you don't even know the law of your own state. How do practice pharmacy without knowing the law? I guess you just make them up to suit whatever you want.
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I'll save you the embarrassment by asking you to do your own research. Note the topic of this entire discussion then come back to me :laugh:
 
Old Timer said:
No it is not. Please show me where that is written. It would unethical and against the oath you take when you become a pharmacist. If you reasonably expect the physician to refill the medication, you are morally obligated and not legally prevented from advancing him or her a few pills in anticipation of the prescriber's authorization.
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Didn't notice the sarcasm in my response?

Back to my original question, would you loan for clonazepam or any other BZDs if they are on these chronically?
 
petty-and-tiny.gif


;)
 
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Who ever posted the Texas Law is the winner. If your State does not have a law like Texas and you "loan" medication to someone you are dispensing a refill without the authorization of the prescribing practitioner which is a violation of the law.

Note Texas law states you can dispense an emergency refill, not to exceed a 72 hour supply, of a prescription drug other than a controlled substance listed in Schedule II. I can't count the number of times I've argued with pharmacists who say the emergency refill law does not apply to controlled substances.
 
Old Timer said:
No it is not. Please show me where that is written. It would unethical and against the oath you take when you become a pharmacist. If you reasonably expect the physician to refill the medication, you are morally obligated and not legally prevented from advancing him or her a few pills in anticipation of the prescriber's authorization.
Click to expand...


I don't think it's quite as simple or as black and white as you are making. I think each situation is unique and requires the careful consideration and judgement of the pharmacist.

http://www.hpso.com/resources/article/54.jsp

Dealing with gray areas
While legal experts agree that rule-bending is inadvisable, they acknowledge that there are gray areas. For example, when a patient’s prescription has run out of refills, a pharmacist who is unable to reach a prescribing practitioner may decide to dispense enough blood pressure medication for the patient to take until the pharmacist can contact the prescriber. While that action could put the pharmacist at risk—he could be accused of practicing medicine without a license—in some cases, he might also have a duty to provide that medication.

For example, if a patient with unstable angina suffers a heart attack because the pharmacist did not provide a refill of his nitroglycerin, the pharmacist may be subject to liability. “It’s a double-edged sword,” said Michael Alfano, RPh, JD, a Philadelphia- based attorney.

A provider’s professional judgment is the most reliable guide in these situations. A pharmacist would have to determine how important the medication is to the health of the patient and the potential consequences of the patient’s missing one or more doses, according to Alfano. He or she would also have to consider the patient’s relationship with the prescriber (Does the patient see the same practitioner regularly?) and the practitioner’s relationship with the pharmacy (Does the medical professional typically authorize telephone refills for medication for a chronic condition?)
 
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MountainPharmD said:
I don't think it's quite as simple or as black and white as you are making. I think each situation is unique and requires the careful consideration and judgement of the pharmacist.

http://www.hpso.com/resources/article/54.jsp

Dealing with gray areas
While legal experts agree that rule-bending is inadvisable, they acknowledge that there are gray areas. For example, when a patient’s prescription has run out of refills, a pharmacist who is unable to reach a prescribing practitioner may decide to dispense enough blood pressure medication for the patient to take until the pharmacist can contact the prescriber. While that action could put the pharmacist at risk—he could be accused of practicing medicine without a license—in some cases, he might also have a duty to provide that medication.

For example, if a patient with unstable angina suffers a heart attack because the pharmacist did not provide a refill of his nitroglycerin, the pharmacist may be subject to liability. “It’s a double-edged sword,” said Michael Alfano, RPh, JD, a Philadelphia- based attorney.

A provider’s professional judgment is the most reliable guide in these situations. A pharmacist would have to determine how important the medication is to the health of the patient and the potential consequences of the patient’s missing one or more doses, according to Alfano. He or she would also have to consider the patient’s relationship with the prescriber (Does the patient see the same practitioner regularly?) and the practitioner’s relationship with the pharmacy (Does the medical professional typically authorize telephone refills for medication for a chronic condition?)
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See I think it is black and white. YOU ARE ALLOWED TO DO IT. Whether you should or not is where your professional Judgement comes in. Just because I can do something does not mean I am required to something. Almost all states have regulations that permit this kind of emergency refill dispensing as it's pretty much common sense. Any pharmacist who refuses to dispense a 2-3 day supply of a maintenance medication to a regular patient who is regularly taking a medication because he or she thinks that it is illegal and therefore makes the patient decide between going to the ER or doing without the medication needs to give up their spatula got the State Board and apologize for being TOO DUMB to be a pharmacist.

I can see this being a real treat for an elderly patient on high dose clonidine or beta blocker and watch them have a hypertensive crisis. I'd like to see that defense at trial. Can you say guilty your honor....... Does it mean any Tom, Dick or Benjamin can have whatever they want whenever they want, no.
 
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MedAffairer said:
Didn't notice the sarcasm in my response?

Back to my original question, would you loan for clonazepam or any other BZDs if they are on these chronically?
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Sorry, I'll have to take my sarcasm meter in for adjustment
sarcasm20meter.jpg
 
MedAffairer said:
Back to my original question, would you loan for clonazepam or any other BZDs if they are on these chronically?
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The answer is it depends. Not usually, but I have depending on the patient. I have to know the patient, know the doctor and feel comfortable the patient would suffer without out it. Little old ladies get treated differently than scum-bags that only fill their XANIES and Percs.....
 
StellargalS said:
Sorry, but I have to know. Is that Thor? He almost looks like a hologram of John Travolta circa 95. Another classic selection Bueller. I want to see you do Danke Shane next! :clap:
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It is indeed! Ah, the pre-Hairspray Travolta days (lets be honest, it was all downhill from there)...good times...good times...

I definitely delve into more serious matters from time to time, but you've got to keep things light too, you know?

cameron.gif
 
BeLikeBueller said:
It is indeed! Ah, the pre-Hairspray Travolta days (lets be honest, it was all downhill from there)...good times...good times...

I definitely delve into more serious matters from time to time, but you've got to keep things light too, you know?

cameron.gif
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Ferris Bueller your my hero!
 
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Dispense 10 and contact the doctor to notify his/her reason for only getting 10. The doctor would usually document it and write the patient a new prescription. This is what we do at walmart.
 
Nguyen said:
Dispense 10 and contact the doctor to notify his/her reason for only getting 10. The doctor would usually document it and write the patient a new prescription. This is what we do at walmart.
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If they got those 10 capsules in September of 2010, this may no longer be necessary.
 
What if the C2 completion is filled within 72 hours but the patient does not pick it up within 72 hours?
 
Nobody ever partials a CII ever
 
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