Controlling the C2's at our CVS

[Pharmgrlnxdor]

New PIC here working at a store that has had a history of being the C2 supplier for the area. Other CVS stores in the area do not order enough or many C2s so people from all over come to our CVS for their C2s. In the beginning I was not able to order as often as the previous PIC and the backlash was pretty intense. Angry threatening people galore. Then later I put through several orders in one week and as soon as we got supply in it was as if we had a neon sign outside because the number of people who showed up to fill C2s was ridiculous. I imposed a two hour wait time....more pissed off people but didn't stem the tide, I imposed a requirement that the PDMP be checked for all C2s by the data entry tech, still the orders flooded in. The workload to deal with these scripts is intense and we get no additional tech hours as a result of them. And when they are refused pts take their other 12 prescriptions with them to another store driving down script count and thus tech hours. Please tell me what I can do and have our staff pharmacists do to not be C2 central?

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[Deja]

deny all new customers that only want to fill controls and the ones that only brings in their C-IIs, you know the ones that one brings in norco #120 every month

Keep feeling C-IIs for your regulars, like you said you don't want them to take all their scripts away... as for 2 hour wait time, your customer will get used to it eventually lol

Speaking of which, this post reminds me that I forgot to order more norco 10s tonight **** my life... we went through 25 bottles in one day lol

 

[Pharmgrlnxdor]

What reason do you give for denying new customers with C2s and those with only controls? Also at this point we have many regulars since other stores do not carry the right qty of C2s. I would say the majority of our C2 customers are regulars with other non control scripts. Easily 85-95% that is part of the problem. The initial weeks where I could not order C2s weekly our script count went down by at least 10% and I had the store manager mentioning it to me weekly.......nice. Please more advice from other PICs abt what to do please to reign in the C2 numbers...

 

[Dr Wario]

CII's are the most difficult and time consuming scripts you will fill for a number of reasons, including they are 100% new dropoff's, most people want to wait, and they have a high correlation with problem customers. CVS does not count controls toward your bonus and does not impact SOS. They give you hours based on controls, but they only count them as just a regular script when everyone knows that they take significantly more time on average.

Sadly the reputation of being the "narc" store is one that is very difficult to get rid of, but when deciding which customers you take and which you deny, may I suggest using the following mindset? The DEA has recently rescheduled two drug entities within the last six months to a higher level of control. This means that there will be more and more regulation on controlled substances going forward, and I would suggest you exert more control as well. At our store, the data entry technician brings every CII to the pharmacist for review and "stock check" before it is typed in. The general criteria I use to determine if a script is filled or denied is a fairly simple formula that is based on how many non-controlled substances they fill, if the CII is only IR form or they have ER plus the IR, and the history of early fills. Notice how it has nothing to due with the patient's age, gender, race or looks, it is simply a necessary formula used to stem the tide so that we can serve the most patients the best that we can with the resources we have.

I really feel your pain, we are still recovering from being the "narc store" but I can tell you to not worry about rx volume so much in the short term. The reputation of being the narc store is known by your good customers also, grandma with 20 medications does not really want to stand in line next to 30 year old "pain patient" jonesing for his next fix. The best of luck to you, and remember, you are not the old PIC and customers and management will need to understand that.

***By the way, if management does give you problems, print out the CVS controlled substance policy and remind them that corporate is behind you and it all comes down to your professional judgement.***

 

[ChalupaBatman86]

The first thing you need to do is put that store manager in his place. Don't let him think he is your boss or has any control over what happens in the pharmacy.

I am guessing the last PIC left in a hurry from the sounds of it.

 

[doublehh03]

I recently took over a "narc" store (transferred near my house). The Sup warned me that the store does a high volume of controlled meds.

When I took over and did my PIC change count, we had 15+ bottles of oxy 30, 10+ bottles oxy 15, 15+ methadone 10... You see the picture. So I knew I had to curb it, and curb it fast.

I had 3-4 corporate complaints in my first month, and a lot of confrontations. But I expected that, and you simply have to be strong and vigilant about it. Hell, I'm even vigilant about ER scripts for 10-20 pills of narcotics.

I think using PDMP helps TREMENDOUSLY. I pretty much decide my decision to fill or not to fill based on that (along with some other factors...).

Just be patient. It took me a month to lay down the law on the store. And we don't get any more complaints b/c those customers have gone away (the bad ones).

 

[Vash350z]

Man, this thread made me feel so much better. I was feeling guilty for having 300 adderall xr in stock.

 

[Pharmgrlnxdor]

So can I ask what specific factors go into your decision? Wario had good factors that I intend to use starting today. And when handing script back to patient you say what?..... I imagine something like I cannot fill this prescription for you, or I am not going to be able to fill this prescription for you. Then they say why of course and I respond by just repeating my earlier statement? What else do you say when handing back the prescription to someone who won't just take it and leave?

 

[doublehh03]

So can I ask what specific factors go into your decision? Wario had good factors that I intend to use starting today. And when handing script back to patient you say what?..... I imagine something like I cannot fill this prescription for you, or I am not going to be able to fill this prescription for you. Then they say why of course and I respond by just repeating my earlier statement? What else do you say when handing back the prescription to someone who won't just take it and leave?

Use PDMP to have your reasons.

Too early? Can't fill. Depending on your early fill rule, if patients always early, I fill the day of. If not, I give a 2 day early rule.
Too many pharmacies? Tell them it's best to stick to one pharmacy for your controlled substance.
Too many doctors? Tell them you have to verify with diagnosis code or pain contract or it's best if they stick to one doctor
Cash and out of area? Tell them it's best to fill at a pharmacy near that doctor's practice b/c it will be familiar with his prescribing habits
Pill mill docs? We don't fill scripts from that doctor period (even if those MDs aren't flagged by CVS, but you know trends in your area)
ER scripts? Check them closely too. Like I have said, I have CURE patients who go to different ER for #10-20 count of Norco 7.5 then the next day 10 and so on. These patients I tell them straight up. I can't fill this and they need to find a pain management doctor.

If they complain that the previous pharmacist always fill it, let them know not every pharmacist operates the same way. I purposely downloaded and printed the red flags from the DEA website, posted on my C2 cabinet, and ensure that my entire team understands that going forward, filling controlled substances is at the discretion of the pharmacist.

I find red flags? I note it in CVS profiles so other CVS will scrutinize those patients more. I notice 24 hour stores tend to fill them willy nilly (obviously b/c they're busier).

I find it best if your entire team is on board with whatever policy you want to install at your pharmacy. Your staff, weekend RPH, floaters, and techs have to understand that narcotic dispensing is a problem at your store and you have to fix it.

Again do not worry about script count. Controlled substances don't make up the metrics. CVS does have a budget for controlled substances for each store, but it won't be used for your script metric. But if you do fill too much, LP will be knocking at your door so it's best to curb it ASAP.

 

[zelman]

Use PDMP to have your reasons.

Too early? Can't fill. Depending on your early fill rule, if patients always early, I fill the day of. If not, I give a 2 day early rule.
Too many pharmacies? Tell them it's best to stick to one pharmacy for your controlled substance.
Too many doctors? Tell them you have to verify with diagnosis code or pain contract or it's best if they stick to one doctor
Cash and out of area? Tell them it's best to fill at a pharmacy near that doctor's practice b/c it will be familiar with his prescribing habits
Pill mill docs? We don't fill scripts from that doctor period (even if those MDs aren't flagged by CVS, but you know trends in your area)
ER scripts? Check them closely too. Like I have said, I have CURE patients who go to different ER for #10-20 count of Norco 7.5 then the next day 10 and so on. These patients I tell them straight up. I can't fill this and they need to find a pain management doctor.

If they complain that the previous pharmacist always fill it, let them know not every pharmacist operates the same way. I purposely downloaded and printed the red flags from the DEA website, posted on my C2 cabinet, and ensure that my entire team understands that going forward, filling controlled substances is at the discretion of the pharmacist.

I find red flags? I note it in CVS profiles so other CVS will scrutinize those patients more. I notice 24 hour stores tend to fill them willy nilly (obviously b/c they're busier).

I find it best if your entire team is on board with whatever policy you want to install at your pharmacy. Your staff, weekend RPH, floaters, and techs have to understand that narcotic dispensing is a problem at your store and you have to fix it.

Again do not worry about script count. Controlled substances don't make up the metrics. CVS does have a budget for controlled substances for each store, but it won't be used for your script metric. But if you do fill too much, LP will be knocking at your door so it's best to curb it ASAP.

Yup. Filling on day due does wonders.

 

[lt23]

I normally find something wrong with the RX and use that and tell them the truth. I use PDMP to help me find something wrong and also tell them the truth (you filled this medication at X pharmacy on X date, etc...). If I can't find anything wrong, but still feel uncomfortable, I'll go back to using the no stock spiel and how it may take a while for it to come in.

So can I ask what specific factors go into your decision? Wario had good factors that I intend to use starting today. And when handing script back to patient you say what?..... I imagine something like I cannot fill this prescription for you, or I am not going to be able to fill this prescription for you. Then they say why of course and I respond by just repeating my earlier statement? What else do you say when handing back the prescription to someone who won't just take it and leave?

 

[Aznfarmerboi]

For me... and I am in a "narc" store.

I turn away any customers who fill only narcs, regardless if they have been going to my pharmacy.

If they are younger than 35, paying cash, them or doctor not from area, and fills high quantity every month, I explain to them why I can not fill for them anymore. Usually 2-3 flags will be automatic no.

If they are old, and legitimately on it, I would have a conversation with them. It usually goes... do you fill all of your scripts at CVS. A lot of times, they do not. They fill only the narc because their independent pharmacy refuses to fill it. I then tell them kindly they have to xfer all of their scripts to my pharmacy so I can monitor, or they have to bring the narc back to the independent. I have gained many scripts, and stopped filling many oxys this way.

If they have never been to my pharmacy, and only filling narc... plus no other meds, I turn them away. I explain to them that I am only allow to order so many and I meet my threshold every month filling for my regulars. Thus, I am not taking new customers for this... They can try somewhere else.

I never tell the customer that we do not have it in stock because that just adds more burden to my partners. They will come and then call every single day. I feel like that is the worst thing to do but yet many pharmacists do so because its the easiest way out. But... the person will probably come back tomorrow when the other partner is in.

I told my partners the only time that it is okay to say that is if they are threatened...

Now my store is not a narc store... or as much...

 

[wagrxm2000]

Just tell them you have to call the doctor, it will be 2 hours. Most patients are on the same strength for months to years. The md isn't doing their job so you can't fill it. Just tell them you don't believe the md is treating them appropriately. After so long your narcs will dwindle.

 

[Bubba98]

Man, this thread made me feel so much better. I was feeling guilty for having 300 adderall xr in stock.

When you have seen orders with 120 bottles of oxy 30 you become numb to it all

 

[type b pharmD]

When you have seen orders with 120 bottles of oxy 30 you become numb to it all

Damn! That is insane. Our store buys over $250k in c2s per month and never seen that .

Are you guys in the top 1% of c2s in the country ?

Imho ,most pharmacists are way more worried about the dea than they need to be and not worried enough about what that kind of c2 volume does to the bottom line.

The "need to see your whole profile" idea is amazing . I instituted 2-24 hour wait time depending on what it looks like I can get away with , at least helps a bit but isn't a long term fix.

 

[Tiger Wong]

In past 6 months, we have not filled a single oxy 30.. I can fill percocet all day long. Oxy 5, 10 or 15 is fine too. it's just plain oxy 30 I have problem with.

 

[Dred Pirate]

Man, this thread made me feel so much better. I was feeling guilty for having 300 adderall xr in stock.

childs play
I worked in a high volume 24 hours store down from a 900 + bed hospital. We routinely had 30+ bottles of percocet, oxy 5, 40+ bottles of methadone 5 and 10. Ocycontin? 20 bottles of each was our par.

Damn I hated that place.

PS - they were robbed at gun point 2 weeks after a quit. Then again 3 months later, but times it would have been my overnight shift.

 

[Bubba98]

Damn! That is insane. Our store buys over $250k in c2s per month and never seen that .

Are you guys in the top 1% of c2s in the country ?

Imho ,most pharmacists are way more worried about the dea than they need to be and not worried enough about what that kind of c2 volume does to the bottom line.

The "need to see your whole profile" idea is amazing . I instituted 2-24 hour wait time depending on what it looks like I can get away with , at least helps a bit but isn't a long term fix.

This was "back in the day". Probably an equal amount of 15mg and maybe 80 methadone and 10/325. I still have a pic of one of our larger orders all nearly arranged on the counter. And our store was limiting fills to rxs within 20 miles at the time. Crazy times.

 

[Pharmgrlnxdor]

So shortly after posting this thread and getting back great feedback I began to implement many of the suggestions. I have had plenty of confrontations and expect to have more until the word gets out that our store isn't C2 city anymore. However, the store manager has been a bit of a problem. For starters on one of the worst days when I was rejecting about 1/3 of the C2 scripts that came my way for too may red flags, I had the store manager come back to the pharmacy after the patient from drive through came in to complain to him that I wouldn't fill his C2 script. So back comes the store manager with C2 script in hand questioning me on why I would not fill it. I gave him several red flags (paying cash, no scripts at all filled at our store or any other store in our chain, other C2s filled at two other different pharmacies in last three months, etc.) He brushes those remarks aside and wants to know why I won't fill it for this great customer of ours. I pretty much told him it wasn't happening and he shouldn't be back there trying to influence me one way or another. Anyway he left in a huff and wasn't very receptive to me for a few days but seems to have gotten over it. Since then he has taken to coming back to the pharmacy every week to tell me how many scripts below budget we are and quite frankly this is getting rather annoying. This last week we dropped nearly 300 scripts and he was totally intense about it today for a good ten minute conversation. I would say he talks to me about our script count like every other to every third day and it is getting old. Is it normal to have the store manager so concerned with script count and questioning what we fill and what we don't fill? I am not backing down but I would love feedback about if others deal with same kind of grilling from their store managers. So far I have used the technique of nodding my head and looking concerned when he speaks about script count and commiserating with his worries. If it were up to him we would fill every C2 that came through the door and go canvas the streets for a few more. What is the best way to deal with this guy?

 

[Unchained]

Continue to ignore him. Front end manager turnover is rather high. He'll probably be looking for a new job soon. Have a good laugh at his expense watching him squirm.

 

[Dr Wario]

Seriously, print out the C2 policy from rxnet and remind him that you have the final word on what gets filled. If this fails, go have a conversation with the DM and let him/her know you will be taking detailed notes of everything that is said so that you have a clear understanding of what exactly the expectations are.

 

[Gombrich12]

The best way to deal with him is an email addressed to him and CC'd to your supervisor detailing exactly why you are rejecting these patients.

 

[Dr.Gonzo]

New PIC here working at a store that has had a history of being the C2 supplier for the area. Other CVS stores in the area do not order enough or many C2s so people from all over come to our CVS for their C2s. In the beginning I was not able to order as often as the previous PIC and the backlash was pretty intense. Angry threatening people galore. Then later I put through several orders in one week and as soon as we got supply in it was as if we had a neon sign outside because the number of people who showed up to fill C2s was ridiculous. I imposed a two hour wait time....more pissed off people but didn't stem the tide, I imposed a requirement that the PDMP be checked for all C2s by the data entry tech, still the orders flooded in. The workload to deal with these scripts is intense and we get no additional tech hours as a result of them. And when they are refused pts take their other 12 prescriptions with them to another store driving down script count and thus tech hours. Please tell me what I can do and have our staff pharmacists do to not be C2 central?

Only you can log in and use your PDMP account. If it is misused by a tech, they will find you out.

 

[Pharmgrlnxdor]

That is not correct. When you originally sign up for the PDMP they send you several informational messages, one of which says authorized users include those that have been given access to use the PDMP login of a registered pharmacist. You can absolutely delegate others to use your login and password including technicians.

 

[zelman]

Only you can log in and use your PDMP account. If it is misused by a tech, they will find you out.

Varies by state

 

[M0df]

This might be just me but I find that store managers tend to communicate with DMs and even pharmacy supervisors a lot. Maybe it is just the ones I have been around. And while they have no direct authority over you, the only way to put them in their place is to hit those targets. Otherwise the things you are not doing to help drive sales, will get back to your bosses very quickly. Those controls don't help your scripts directly and you need to find a way to convince your store manager that eventually what you are doing will translate into higher script count. It really depends on the dynamics of your district.

 

[Mcat14]

For me... and I am in a "narc" store.

I turn away any customers who fill only narcs, regardless if they have been going to my pharmacy.

If they are younger than 35, paying cash, them or doctor not from area, and fills high quantity every month, I explain to them why I can not fill for them anymore. Usually 2-3 flags will be automatic no.

If they are old, and legitimately on it, I would have a conversation with them. It usually goes... do you fill all of your scripts at CVS. A lot of times, they do not. They fill only the narc because their independent pharmacy refuses to fill it. I then tell them kindly they have to xfer all of their scripts to my pharmacy so I can monitor, or they have to bring the narc back to the independent. I have gained many scripts, and stopped filling many oxys this way.

If they have never been to my pharmacy, and only filling narc... plus no other meds, I turn them away. I explain to them that I am only allow to order so many and I meet my threshold every month filling for my regulars. Thus, I am not taking new customers for this... They can try somewhere else.

I never tell the customer that we do not have it in stock because that just adds more burden to my partners. They will come and then call every single day. I feel like that is the worst thing to do but yet many pharmacists do so because its the easiest way out. But... the person will probably come back tomorrow when the other partner is in.

I told my partners the only time that it is okay to say that is if they are threatened...

Now my store is not a narc store... or as much...

Damn! That is insane. Our store buys over $250k in c2s per month and never seen that .

Are you guys in the top 1% of c2s in the country ?

Imho ,most pharmacists are way more worried about the dea than they need to be and not worried enough about what that kind of c2 volume does to the bottom line.

The "need to see your whole profile" idea is amazing . I instituted 2-24 hour wait time depending on what it looks like I can get away with , at least helps a bit but isn't a long term fix.

The "need to see your whole profile" idea is amazing. I am gonna try at my store lets see how may people will actually transfer their whole profile. I have been ordering/keeping those narcs on hand for legit people for a while, now I guess its time for me to reap the fruits

 

[drstd]

New PIC here working at a store that has had a history of being the C2 supplier for the area. Other CVS stores in the area do not order enough or many C2s so people from all over come to our CVS for their C2s. In the beginning I was not able to order as often as the previous PIC and the backlash was pretty intense. Angry threatening people galore. Then later I put through several orders in one week and as soon as we got supply in it was as if we had a neon sign outside because the number of people who showed up to fill C2s was ridiculous. I imposed a two hour wait time....more pissed off people but didn't stem the tide, I imposed a requirement that the PDMP be checked for all C2s by the data entry tech, still the orders flooded in. The workload to deal with these scripts is intense and we get no additional tech hours as a result of them. And when they are refused pts take their other 12 prescriptions with them to another store driving down script count and thus tech hours. Please tell me what I can do and have our staff pharmacists do to not be C2 central?

This thread is more than 5 years old, but I’ll comment anyways. For those of you experiencing the same thing, it’ll go away in about 90 days. The problem patients will get upset and find another pharmacy. I think it is essential that you ask the patient ”why are you going to so many doctors” “why do you keep going to the ER” “does Dr. X know you’re being prescribed Percocet by Dr. Y” “why do you keep switching pharmacies” before denying care. The patient that keeps going to the ER may not be able to afford thousands of doctors for a CT scan and work up for a pain doctor while they work out a payment arrangement with the ER. Some may be being profiled by doctors (they look and are sketchy AF) and are legitimate patients nonetheless. In that case and for those people, running out of oxycodone may be an emergency similar to running out of a beta blocker or antipsychotic. Maybe they may be legitimate in other ways. They are in college (check the city). You’re off a major highway on the way to their home from the doctors office they drive to the city to see. (Our pharmacy is like this. We occasionally get sketchy patients b/c of GoodRx and I’ll check on google maps if we’re on the way and we actually are) Their kids have an X on Wednesday and Thursday and they work all day. I’m not saying every one is, but that is *sometimes* the case. Obviously it can be overuse/polypharmacy The technician issue can be fixed by recruiting floaters. Text every one. Ask every one if they know another and keep doing that. I know one pharmacist who’s well known with the techs for that but now she gets to pick and choose.

 

[owlegrad]

That was a very thoughtful reply. Something I would differ on is the “fill it once and tell them next time they need to X”. Imo that is terrible advice. If you aren’t willing to fill for the patient regularly (based on the current RX without any changes in the future) do not fill at all. They will come back and they will try to wear you down to fill it again. An ounce of prevention is worth a pound of cure.

That’s just me though, to each their own.

 

[owlegrad]

It is illegal to fill a prescription to maintain an addiction. Someone at risk for withdrawal can go to a treatment center. I absolutely would not fill even a single tablet of a script for that if that is what I thought was happening. It is literally illegal to do so. You aren’t even a healthcare provider at that point imo.

Otherwise you make some good points. There was a time I used to give people the benefit of the doubt. I very quickly became jaded though. Kudos to you for maintaining that bright eyed bushy tailed youthful optimism.

 

[owlegrad]

Yes, dependence and addiction are different. Since your example was addiction that was what I was addressing.

 

[meltyblend]

I think all the advice on the thread has been very good and should be read by anyone who practice in the retail setting. I just want to add that the best way to deter these patients from coming back is to have everyone in the pharmacy on board. ALL the pharmacist working in the store needs to agree on the policy. If you don't want to carry oxy 30 (which realistically why would you) make that a rule. If you will only fill it a day early, make that a rule. As long as everyone in the pharmacy agrees and actually follow it, eventually it catches on and these patients will know to go elsewhere. You can't have one person who will allow things to slide because all those C2 patients will ask for that particular pharmacist or only come in on the days that pharmacist is working.

I know filling prescriptions should be up to the pharmacist's disgression but you want to prevents situations where the patient will say, "Well X always did it for me. Why can't you?" That makes it seem like they just need to find another person willing to do it or that they can eventually wear you down because it's not a strict rule. Make it clear that you won't be filling it, and neither will your partners, so they know that no matter how many times they ask the answer is still no. Being firm but not antagonistic is also important.

And in regards to the front store manger coming to the back demanding you to fill the script, they can go kick rocks. It's not their license t on the line and, if someone ended dying from an overdose, they're not the person liable. Hell, if a DM wants to push you into it, tell them to fill it themselves. No one should ever be forced into fill any controls they are uncomfortable will. And if there's pressure from above, email the DM directly and state that you don't feel comfortable filling the script with clear and concise reasons. Document it and start a paper trail,