In CA can a pharmacist substitute strength on a Rx?

[mooseRx]

I'm studying for the CPJE and reviewing some law. My class notes from PassNaplexNow and my professor are conflicting. I learned in school, and in practice, that a pharmacist cannot substitute strength (lisinopril 20 mg 1 tab po once daily =/= lisinopril 10 mg 2 tabs po once daily). The PassNaplexNow course says that substituting strength is allowed. Is substituting strength allowed in California?

I think the relevant regulation is: B&PC 4052.5.

(a) In addition to the authority allowed under Section 4073, a pharmacist filling a prescription order for a drug product may select a different form of medication with the same active 62 chemical ingredients of equivalent strength and duration of therapy as the prescribed drug product when the change will improve the ability of the patient to comply with the prescribed drug therapy.

(f) This section shall not permit substitution between longacting and short-acting forms of a medication with the same chemical ingredients or between one drug product and two or more drug products with the same chemical ingredients.

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[JustFillIt]

I don’t know about California - but in my state, and any reasonable state, dispensing the dose that the provider ordered is entirely legal. Why would dispensing 20mg of lisinopril, if the provider asked for 20mg, be illegal?

I suppose I would recommend to counsel the patient, especially if they are used to picking up a regular single pill dose, to give them a heads up. In retail - I would likely mark the Rx as “mandatory counsel” with a note to notify the patient. This is good practice.

Otherwise, I could perhaps see this be an issue with controlled substances in some cases. But overall - no, it is certainly not illegal to dispense a dose the provider ordered.

 

[Dred Pirate]

I don’t know about California - but in my state, and any reasonable state, dispensing the dose that the provider ordered is entirely legal. Why would dispensing 20mg of lisinopril, if the provider asked for 20mg, be illegal?

I suppose I would recommend to counsel the patient, especially if they are used to picking up a regular single pill dose, to give them a heads up. In retail - I would likely mark the Rx as “mandatory counsel” with a note to notify the patient. This is good practice.

Otherwise, I could perhaps see this be an issue with controlled substances in some cases. But overall - no, it is certainly not illegal to dispense a dose the provider ordered.

common sense tell you that you are right - I mean, when I moonlighted at retail, I would do this without giving it thought - but I know way to many people who would call to get approval and it made me embarrassed for our profession. That being said, I wouldn't be the least bit suprised if there were some states that had regulations against it, whether intentional or not.

Sort of like the Illinois state formulary - not sure if that is still a thing or not.

 

[radio frequency]

I‘m curious to hear from California pharmacists on this. There is the answer for the test, and then there is real life practice, which may sometimes differ slightly if you want to survive without getting eaten alive. At my past two employers, the rules differed greatly. At the first, they would fire me if I didn’t call on any strength substitutions, and at the the second they encourage it when it is expedient, and it is done regularly. I don’t know if legally it would hold up in California, but I haven’t ever heard of a pharmacist disciplined for this unless something got screwed up.

 

[aqb]

Surprised this is even a question.

I switch it without hesitation. Why waste everyone’s time? In what world would a provider refuse that?

I switch capsule to tabs depending on inventory too. If MD wrote for solution and pt is okay to switch to tab per ins coverage no problem with me.

Some rphs call on the littlest things, jts no wonder they’re always backed up.

 

[JustFillIt]

I‘m curious to hear from California pharmacists on this. There is the answer for the test, and then there is real life practice, which may sometimes differ slightly if you want to survive without getting eaten alive. At my past two employers, the rules differed greatly. At the first, they would fire me if I didn’t call on any strength substitutions, and at the the second they encourage it when it is expedient, and it is done regularly. I don’t know if legally it would hold up in California, but I haven’t ever heard of a pharmacist disciplined for this unless something got screwed up.

I agree. I would say that, unless we are talking cii’s or some sort of weird thing - if you counseled a patient (and documented the counsel) that you made an adjustment to get them the proper dose, I can’t see any way a pharmacist could get sued for this type of thing.

 

[radio frequency]

Surprised this is even a question.

I switch it without hesitation. Why waste everyone’s time? In what world would a provider refuse that?

I switch capsule to tabs depending on inventory too. If MD wrote for solution and pt is okay to switch to tab per ins coverage no problem with me.

Some rphs call on the littlest things, jts no wonder they’re always backed up.

It’s a question because they want to pass California’s version of the MPJE. They didn’t ask about actual practice, they asked about law.

 

[mooseRx]

Surprised this is even a question.

I switch it without hesitation. Why waste everyone’s time? In what world would a provider refuse that?

I switch capsule to tabs depending on inventory too. If MD wrote for solution and pt is okay to switch to tab per ins coverage no problem with me.

Some rphs call on the littlest things, jts no wonder they’re always backed up.

I know it must seem like a dumb question. I have just been getting conflicting info about this topic. I think some people I have asked are confusing their own pharmacies practice and what the law actually says.

 

[sunnyandseventytwo]

I know it must seem like a dumb question. I have just been getting conflicting info about this topic. I think some people I have asked are confusing their own pharmacies practice and what the law actually says.

Let me preface with: I've never worked retail full time in California.

When I first started moonlighting, the PBMs were forcing tablet splitting on patients. The interns would chastise me for subbing without calling the doctor for permission. I figured as long as the patient consented, I'd feel pretty comfortable defending my actions in front of the board.

Several years later, the BOP clarified that pill splitting was indeed allowed in an issue of the Script. They still mailed everyone a hard copy back then.

There are no California laws or pharmacy regulations specifically forbidding pill splitting. Therefore, the pharmacist’s professional judgment and the patient’s best interest should prevail when determining whether a pill split is in order. The patient should be able to make the final decision.

https://www.pharmacy.ca.gov/publications/07_jul_script.pdf

I'd extrapolate that backwards to your lisinopril question and say there are no laws or regulations prohibiting your strength change.

 

[aqb]

It’s a question because they want to pass California’s version of the MPJE. They didn’t ask about actual practice, they asked about law.

Whoops, my bad. Read this real quick after a long day of retail enabling my tunnel vision