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Frustrating Scripts

Discussion in 'Pharmacy' started by jasonkido, Jan 29, 2012.

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  1. jasonkido

    jasonkido

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    Just got a call at 10:00pm to fill a script with 3 problems.

    First of all it was written as lortab 10/650 liquid when the concentration should be 7.5/500 and written as 20ml per peg q4h. That had to be confirmed with the doctor. Of course, theres a problem with the doctor. The md signature is scribbled and theres no identifying info such as a letterhead, dea, npi, nada. Only the address of the hospital was on the letter head. Then there was no quantity.

    I work in a long-term care pharmacy and we get narc scripts like these about once a week. I know this is a common occurence in retail but what are your pet peeves with rx's. For me its the above but good thing it doesn't happen often.
  2. PharmDstudent

    PharmDstudent

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    Permetherin lotion for scabies is the worst! It's the cream people! :mad:
  3. farmadiazepine

    farmadiazepine

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    Imitrex 50. Take 1 tab by mouth every day. #30 x1 refill.

    Let's just keep the shotgun approach of throwing imitrex at the problem instead of finding out whats really going on.


    Advair
    Inhale 1 puff every day
  4. kvl1027

    kvl1027 Member

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    For me it's the arrogant phsycians who dont think they should have to print their names out or, at the very least, legibly write their DEA numbers at the bottom of the script. I mean whoTF do you think you are? Are we just supposed to know your signature, it's not like you are the only "Patel" or "Smith" who practices medicine.
  5. Digsbe

    Digsbe

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    They could just be in a hurry or have naturally horrible hand writing. I wouldn't say all prescribers who write problematic scripts are "arrogant." The worst I've seen were done by the strict calculations in textbooks. I've gotten a script for amox 631.89mg before (weight calculation dosing) and also had a Cialis script for 7 pills instructing the patient to take one each day. I asked my pharmacist if we should clarify due to this scripts as it is written is almost universally taken "as needed" and not taken every day.
  6. npage148

    npage148 Senior Member

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    lantus UD #4 vials

    Valium 10mg, 1bid-tid MDD1 #30
  7. spacecowgirl

    spacecowgirl brr

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    Advair + abx + Robitussin AC for a URI.

    Nasonex PRN.
  8. Carboxide

    Carboxide

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    Lantus 4 vials could be legit...some people take huge doses...and could be a 3 mo supply
  9. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    Yeah, but you need directions. The most I've ever seen is 180 units/day. That person got 3 boxes of 5 pens each. Not quite a one month supply but we can't fill for more than 30 days at a time with this particular insurance.
  10. Ackj

    Ackj

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    Drives me crazy when one vial or one box of pens lasts like 40 days, and the insurance company limits them to 30 days. You're basically being forced to submit a fraudulent claim because it rejects otherwise.
  11. jasonkido

    jasonkido

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    I had a #qs for a fentanyl patch script last week. First time I've seen anything like that. How lazy can you be to not figure out the quantity for a month's worth or better yet decide if you want 1 or 2 boxes. I also had another fentanyl script written prn.
  12. Carboxide

    Carboxide

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    That's stupid for about a hundred reasons. For one, the pens really don't work well for volumes above 30 U/dose. If you're giving 180, you really have to stick yourself five times. That's ridiculous.

    I wish we could break up the pens. Although it's nice for patients that each pen is good for 28 days. Sometimes you get the Type I little kids who only need like 10 U/day and the pens are super nice for that...one box lasts forever.
  13. kvl1027

    kvl1027 Member

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    You are but a student and can not fully understand the frustration. I did not say all problematic scripts were written by "arrogant" physicians, but some local physicians seem to think the local pharmacists should "know" their signature by now.

    Also, I would like to say that you may become part of the problem with pharmacy if you don't get on the same team so to speak. Get some backbone, don't defend physicians for not doing their job correctly, because it devalues you. "Oh, it's ok, they were probably really busy" Who gives a sh!t?!!!! I am really busy, I have a patient that is with a sick kid who is waiting because I have to find out who the hell the Dr. who wrote the script was, because they were in a hurry and scribbled some bulls**t down at our expense.

    When I was on rotations I went to a P&T committee meeting in a very large Florida hospital. The was a cardiologist in the meeting who, without a doubt, was a very well positioned physician in the hospital and community. The Director of pharmacy for, not just that hospital, but for every hospital in the healthcare system, which is probably about 12 hospitals was there as well. At the end of the meeting the cardiologist got up from the table and left his garbage on the table and while the physician was about to walk out, the Director of Pharmacy went over and picked up the cardiologist's trash and clean up his mess:eek: Everyone else in the room, cleaned up their own mess, but this guy just walked away and left a mess board room. If I was the DOP I would have said, Dr. if you wouldn't mind cleaning up your crap, environmental services does not come into our board room to clean.

    Don't be just another pharmacist making excuses for some physician. Tired, busy, stressed out, the script should be written properly. Mistakes are going to happen, but you should know how to write you fricken name legibly.
  14. 007rx

    007rx

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    I do not mean to digress from the topic but someone made a good point earlier. Say for example a physician orders Lantus Solostar 10 units SC QHS #1 box (just to clarify, one box is five pens, each pen contains 300 units).

    As someone earlier mentioned, one box in this case would last 150 days assuming that the patients dose is never titrated up or down, and that the patient stores it correctly. If the insurance only covers thirty days at a time, is there anything wrong with opening the box and dispensing a single pen? (rather than giving them a 150 day supply and billing it as a 30 day supply).

    Does dispensing a single pen make the product adulterated? Why has it become standard practice in these scenarios to bill 150 days worth of medicine for thirty days? It makes more sense to actually dispense what is being billed for. Does sanofi-aventis actually state on the box not to open it up and dispense individual pens or something? Or do insurances companies have an unwritten agreement on certain medications that allows us to commit pseudo-insurance fraud?
  15. kvl1027

    kvl1027 Member

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    We would never dispense a single pen at my pharmacy, but that is most cost driven. At $200 / box, I am not going to have an open box of pen's that I can't return and may or may not ever sell the remaining pens since most patients get a whole box.

    Typical the insurance companies wont run an audit if you are dispensing the smallest package size available, but you know they are the most powerful people in healthcare so I guess they can do what they want.
  16. 007rx

    007rx

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    I understand not being able to return it, but couldn't you just use that opened box for the same patient's remaining refill(s)? Or if the process of opening pens out of boxes became as common as taking pills out of bottles, couldn't you just dispense it to another patient? My pharmacy dispenses Lantus Solostar frequently (I'd estimate fifty boxes per week), so we wouldn't have any issue with extra pens lying around. Although I can't say the same for all pharmacies.

    If insurances aren't going to audit over it, it's not an issue I guess. But it's silly that they aren't running audits or changing allowed coverages because it really would cut costs.
  17. GreyFox2002

    GreyFox2002

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    The truth though is that they CAN run an audit on you, and if they do, they are going to recoup the cost of that fill (plus any previous fills for that patient by your pharmacy).

    The cost of saving a pen here or there may not be worth the potential of an audit that can cost your pharmacy thousands of dollars. Plus, running a box of insulin pens that would be a 150 day supply as a 30 day supply knowingly could possibly be looked as fraudulent claims. This could cost your pharmacy/company much more money in terms of fines. That's my opinion though.

    What do I do? Break up the pens, put it in a sealed bag and label the bag. My pharmacy's inventory is under control and I almost always get credit for expired products (I'd say about 75%). Anything else is written up as a known loss. It's no different from giving a patient 30 tablets of some stupid overpriced acne tetracycline derivative, like Solodyn, Doryx, or Oracea, that only comes in a 100 count bottle (of course) only because the patient has a drug rep coupon. Then when they go to get a refill and the coupon expires, they find their copay is $80. Shockingly, you see a script a day later for good ole doxycycline hyclate. Those other 70 tablets? Their going to sit there until they expire probably.

    The likelihood of the pens actually expiring however is rare because A: the patient gets refills and B: other patients may fall under similar situations. Insulin pens are pretty common so there is no point risking an audit for something you're very likely to keep using Of course, I don't break up things like eye drops with day supply for obvious reasons. The insulin pen however is located within a sterile device so it's fine to bust open the box.

    That's my long-winded opinion. It's important to manage pharmacy inventory, but you don't need to micromanage everything. I don't and mine's under control, anyways.
    molyhelp likes this.
  18. kvl1027

    kvl1027 Member

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    We just don't do it. Do you work for an independent or retail chain. If I worked for a retail chain, I would be breaking boxes open all day. But with mail-order pharmacy destroying us and crappy 3rd party reimbursements kicking us while we are down, we would rather let a drug die on the shelf.

    How would you bill for a Premarin cream if the patient was supposed to use 1 gram twice weekly and their insurance only pays for 30 days. Would you squirt 8 of the 42.5grams from the tub into an ointment jar and bill for 28 days? I hope not.

    There is no guarantee the patient will come back for the refills and most patients require a full box. Its just something we don't do. Unless the stuff is dirt cheap or we have a lot of patients taking it, but frankly, not that many patients are using the solostar pens. Not in my store, so we always dispense a full box.

    If the insurance company comes in to do an audit, I don't care how much you dot your I's and cross you t's, they are going to burn you for something. I guess we just tow the line on some things.
  19. farmadiazepine

    farmadiazepine

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    Do not open the boxes... I hate when RPhs do that thinking they know best..

    The fact of the matter is that this is insulin .. and in diabetics using insulin, their insulin requirements are CHANGING..

    I hate when I work in a store floating and someone calls me angry because they were given 2 novolog pens now need more, but the tech tells them its too soon .. well you know what, its not too freaking soon, its the dumb a * s * s* RPh who gave exactly 2 pens for 25 days and now the patient has been using more insulin after visiting their endocrinologist the day after..

    Just give them the box, just give them the box. Insulin requirements CHANGE, goes for all insulins, humalog, novolog, lantus, apidra, levemir, whatever
  20. Digsbe

    Digsbe

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    Honestly, I do think that you're right. I misread your post as an attack upon physicians and that was my bad. I also looked at my comments and I retract my argument. Being busy or in a hurry shouldn't be an excuse to compromise patient health. When prescribers screw up a prescription or don't have the decency to legibly indicate who prescribed the medication then that's their fault and there is no excuse. We are extremely busy in pharmacy too, and our stress level/workload shouldn't be a justifier for making an error on filling a script on our end of things.

    Some people are genuinely arrogant. I've known some physicians (and pre-med students) who are incredibly arrogant and judge others. I've known of a physician that got mad at a pharmacist I worked with due to the pharmacist telling the doctor that you don't increase a glimepiride dose to three times a day when a diabetics sugar levels are unsatisfactory (I believe this was the drug, I may be wrong). The physician flipped out and told the pharmacist to know her place. She told him it's her job to keep him from prescribing things that are unhealthy for a patient and that her degree as a doctor of pharmacy and licensure as an pharmacist means that she is the leading authority on drug information. There are some physicians that view pharmacists in a bad light, there are those that don't and will work with pharmacists and recognize their speciality and leading authority in drug knowledge. I've known some pre-med and medical students that think pre-pharmacy/pharmacy students are nothing more than med school rejects who can't make the cut.

    Regardless, I do agree and I think that prescribers should be fully responsible and accountable for how they write a script.
  21. 007rx

    007rx

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    When insulin requirements change we need the order from the physician to bill for that change. Just as if a patient is taking one Norco 10-325 mg tab BID PRN pain, and the physician increases the dose to QID, we would need new a new order. If we change the sig on the prescription without physician orders, that is adulteration/misbranding and the insurance company will take their money back.

    Call the physician, get a new verbal order - it's no big deal. If its the weekend, give them another pen until you can get a new script.
    Last edited: Jan 31, 2012
  22. genesis09

    genesis09 Senior Member

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    I don't think our computer system even allows us to bill for individual pens. It is a unit of use issue. You can't break-up creams or inhalers when the day supply is greater than 30.
  23. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    I know mine doesn't allow it. I also think the NDC is for 5 pens so dispensing just one would be misbranding.
  24. 007rx

    007rx

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    Following that logic, dispensing 30 tablets from a stock bottle with an NDC for 1000 tabs of simvastatin 40 mg would be misbranding because the entire 1000 tabs weren't dispensed.
    Last edited: Jan 31, 2012
  25. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    You're probably right, but I'm still not sure you are supposed to break the package. I know we never do. :shrug:
  26. Ackj

    Ackj

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    Okay, so you break up the box of insulin pens... but what do you do for a vial of insulin? Or an inhaler, or test strips, or anything that can't be broken up?

    You're obviously going to bill it as a 30 day's supply so that it goes through, which could be audited and charged back. Has anybody been audited for that? Most likely and hopefully not, but I'd like to hear your opinions.
  27. 007rx

    007rx

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    Right. I understand completely. We don't break up the boxes either. It's just one of those things that we do in pharmacy that nobody questions. But I'm just overly curious as to why. We once had a lady who's physician office would take forever to approve refills and she eventually ran out of Lantus. She asked if we could give her one pen to hold her over. Being an intern, it wasn't up to me so the pharmacist made the decision not to break up the box. If I was the pharmacist I would've done it and saved her box for when the refills were approved. She was a regular customer. We give out a few pills to regular patients all the time when they run out of maintenance meds. Why not break open her future box to give her one pen now and the remaining four pens when her physician phones the script in? It's not like she was going to take off with it and never come back. Filling a partial refill without any approved refills remaining is against the law we can all agree (in my state anyway), but most of us do it for ethical purposes by using professional judgement. Anyway, sorry for taking the thread off-topic lol.
  28. kvl1027

    kvl1027 Member

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    In this case if it was a regular customer who hadn't had a dosage change in lantus for a long time and they were out of refills, I would break the box give her one pen, and then when the script came in I would bill her insurance for the full box and then give her the rest.

    I have never been audited for insulin pens. I have seen some audits for insulin vials, Levemir, but it was a gross miscalculation of days supply. The tech made a mistake and it was not caught by the pharmer. If you dispense the smallest package size available on most drugs and bill it for 30 days, even if it is actually greater than 30 days you will most likely not get audited.
  29. kvl1027

    kvl1027 Member

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    We are allowed to dispense an emergency supply of medication without a refill authorization for up to 72 hours worth. On maintenance meds of course.
  30. Farmercyst

    Farmercyst Lowest common denominator Moderator Emeritus

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    All this talk of insulin reminds me of Lantus 6 units Qday increase by 3 units every 3 days until BG <140 #30. 3 refills So what's the day supply on that one? And each refill? At least with the refill, you could ask the patient how much they're injecting, I guess.
  31. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    I would call the MD and have them give you a max # of units per day and calculate the days supply based on that. At least until they get stablized on a dose. Then you should redo the sig and the days supply. I hate checking something that's been refilled a bunch of times but no one has ever updated the sig after the titration period.
  32. njac

    njac Senior Member

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    now I have a question as I've never worked retail.

    It annoys the living crap out of me when a prescriber (usually our midlevels) have determined they want "2/3 teaspoon" or something or arbitrarily pick some strength and then give me the volume they want. No.

    What makes the most sense to me is to just order in mg and let the pharmacy pick which strength they have and fill it with the necessary quantity. What do you all in retail land prefer?
  33. 007rx

    007rx

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    If the script is written for "Lantus" like you said, and not "Lantus Solostar", then I'm assuming we are dispensing vials, which are only good for 28 days at room temperature after punctured. A patient starting off titration with 6 units QD will definitely not use up 1000 units after twenty eight days even after they titrate up 3 units Q3 days for 28 days.

    Since they are starting off Lantus therapy initially, I would only dispense a single 10 mL vial to them, even though it was written for three vials. By dispensing three vials you are setting yourself up for a potential indisputable audit, and you would be unable to label those other two vials with correct instructions after the patient finds a maintenance dose. I would bill the single vial as a 28 day supply and have the patient call me and tell me when they are stabilized on a dose. Then I would document that conversation on the hardcopy and re-scan it in the computer so when future pharmacists are verifying refills they wouldnt be confused. I would fill all refills with a day supply based on the new maintenance dose and update the sig for insurance purposes.
  34. kvl1027

    kvl1027 Member

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    I know it seems like a little extra work, but you may want to consider having you tech break it up into two separate rx's, one for the titration period and one for the regular dosing. I will just separate it out and give the maintenance rx the refills and put it on hold. When the patient is finished with titration then they call in to have to on hold rx filled.
  35. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    Patients don't want to pay two copays.
  36. 007rx

    007rx

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    This.

    And All4MyDaughter, the patient does NOT have to pay two copays for the price of one. I do this with all antidepressants and antiepileptics and other drugs that require titration. Example:

    Ordered Prescription
    fluoxetine 20 mg caps
    1 cap QD x2 weeks then increase to 2 caps QD
    #60 with 3 refills

    Dispensed titration prescription:

    Rx:10012
    fluoxetine 20 mg caps
    1 cap QD x2 weeks then increase to 2 caps QD
    Dispense #46 with 0 RF
    (bill as a thirty day supply)
    $5 copay

    On-hold prescription with maintenance refills:

    Rx: 10013
    fluoxetine 20 mg caps
    2 caps QD
    #60 with 2 RF
    (bill as a thirty day supply)
    $5 copay



    Yes, if you do the math they will lose out on 14 capsules by doing it this way. Personally, I wouldn't be particularly concerned. But if you were, you can get past that by putting the original quantity prescribed as #196 and dispense 60 each time. Or you can simply call their physician and get a new script when they are out of refills. At this point however they have hopefully been evaluated for the need to increase the dose or discontinue therapy.
    Last edited: Feb 6, 2012
  37. Ackj

    Ackj

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    Unless it's one of those odd insurances where it's something like $5/month but 3 months for $10, that shouldn't matter if you bill the titration as 30 days, and the maintenance as 30 days.
  38. genesis09

    genesis09 Senior Member

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    don't make up your own concentration for liquid medications
  39. mipharmd

    mipharmd PharmD/M.P.H

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    I have seen pharmacies being audited about Lantus Solostar and other insulin pens. The auditor said that the opening the box does not compromise the insulin in the pens. He said just because tablets come in 100 ct or 1000 count bottles does not mean we dispense 100 or 100. You dispense what is needed for the day supply. If its over by a few days, they usually dont care, but if you are giving a box that is over 1.5 month supply they will come and take their money.
    For the person who said cream, test strips etc- You usually are suppose to give the lowest qty applicable.. so testing BID would mean that you give a box of 50 for a 25 days supply, not 100 for a 30 day supply. Eye drops the same thing- drs write for 15 ml or 10 ml and you only need 5 ml for the month..

    The few pharmacies that have been audited now just open the pens because they are going to be on insulin,and its not like we are short on patients who get insulin!!
    molyhelp likes this.
  40. Farmercyst

    Farmercyst Lowest common denominator Moderator Emeritus

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    I'd much rather the mgs. Though I've called a prescriber or two when they fail to round their wt based doses and have them changed to something the patient can actually measure. 1.3 teaspoons vs 1.25 or something like that. Funny that CA medicaid covers prednisolone 15/5, but not 5/5. So I have to convert those doses somewhat frequently, which leaves 1/3 teaspoons and such.
  41. farmadiazepine

    farmadiazepine

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    Yea you don't work in a busy pharmacy, do you? Thanks for stating the theoretical right answer. The real world works differently than theory though. Not to hate on you, but your answer doesn't work in pharmacies actually doing high volume.
  42. farmadiazepine

    farmadiazepine

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    Not to hate on you either, but stop with the theoretical answers. Again, I assume you don't work in a high volume pharmacy. Why would you ever do that to a customer? 1) Make them pay 2 copays 2) Do that for prozac Rx which is not going to get audited anyway?
  43. npage148

    npage148 Senior Member

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    The copays are not going to change but you technically need to call the doctor to get the two new scripts, 1 for the titration and the other for maint
  44. 007rx

    007rx

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    I actually work in a pretty high volume store in my opinion (2500 scripts per week). And we are open 24 hours. Not to hate on you, but It's not that hard to take the time to do basic tasks.

    And they pay one copay for their first fill (which is a thirty day supply) and a second copay when they pick up their refill, one month later (which is also a thirty day supply). Which part do you not follow? In this specific example they pay 10 dollars in a 60 day period.
    Last edited: Feb 10, 2012
  45. 007rx

    007rx

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    How does this answer not work in the real world setting? It's quite simple: Dispense one vial as a twenty eight day supply, have the patient give you a 60 second phone call when they establish their dose, and then make the appropriate change in the computer. If your pharmacy is too busy, make a note to do it during downtime. There's always downtime at some point in the day. If your pharmacy doesn't have even the slightest downtime (not even on the weekend), I feel sorry for you and have very much respect for you to work in a store that busy.

    Anyway, it's just my opinion of what I would do to cover my tracks and avoid an audit. What would you do if you had that prescription for Lantus at your pharmacy Farmadiazepine? What's the most practical, "non-theoretical" thing to do to not waste your time and avoid an audit simultaneously?
    Last edited: Feb 10, 2012
  46. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    Says the person who has never worked a single day as a pharmacist. Not to hate on you, but when I work as dispensing pharmacist, I don't have time a lot of free time. During downtime, I'm getting copies, checking the voicemail or getting things ready for the next rush. Doing things the simple way often wins out of necessity.
  47. 007rx

    007rx

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    Correct, I'm not a pharmacist for another 6 months. But I do everything the pharmacist does, except by law I can't verify scripts. The pharmacist sends all copys, consultations, phoned-in scripts, and rx issues to me, on top of data entry/drive-thru/fill. He's trying to prepare me for when I am in charge. Yes, I understand that having to verify orders changes the game, and I'm sorry if I played down the time that you guys have to manage on top of all of your other duties. I can't fully appreciate it yet since I haven't been in your shoes so I take back what I said.
  48. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    Yes, you do everything the pharmacist does, except the thing that REALLY matters. The #1 reason the pharmacist is legally required to be in the pharmacy. No worries, when I was a student, I thought the same way. It really is different when you are in charge.
  49. kvl1027

    kvl1027 Member

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    The patient is not really paying two co-pays they are paying one copay for each 30 days of medicine. If you dont do it this way then when the patient is on their maintenance dose the sif will still have the titration dose and may cause some confusion. Whether you break it into two rx's or go back and change the sig later, you will have to take some extra time.

    If the patient is paying two copays, so what? They have to titrate and I have to bill accordingly. It will only happen once, it is not really a big deal.
  50. Ackj

    Ackj

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    Yeah, either way, $5 per month or $10 for 60 days, it's all the same. I suppose if you think about it, making it into two transactions is more work and expense, you're filling another rx, you need to waste an extra vial on them, another label, another patient info packet, another receipt from the register, and the manpower to do it all twice. Seems like that could add up if you did that for every patient, considering the pharmacy isn't earning more by doing so. I've wondered if that was part of the reason why pharmacies had the push to 90 day rxs instead of the traditional 30.

    Of course, maybe the extra cost is offset by more front-end purchases and traffic due to the patient being in the store more. Tough to say.

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