Is it okay to fill a CII 9 days early when the doctor has changed the sig?

[owlegrad]

Owlegrad,

Here is what I am understanding from you:

1. You are saying that by recording 540 mL instead of 450 mL, the problem is solved.
2. I am working under the assumption that you are:
   1. dispensing and recording this as a 30 day supply.
   2. reporting it as a 30-day supply to the PDMP.
   3. billing insurance for a 30-day supply.

In the two states that I am licensed in, you cannot give extra. If that means you waste some, then that's what you do. When you do inventory, you are comparing what you purchased from your supplier vs the quantities you dispensed. The quantity dispensed is determined by the SIG or the total quantity written on the prescription, whichever is less. The quantity that should be dispensed can't possibly be determined by what's convenient to dispense.

If what you purchased does not equal what you have on the shelves + the quantity that you should have dispensed, then you should have a record of waste somewhere. If you do not, then you were over-dispensing. Thus, your inventory is short. Those extra mL should have never been sold because they were not dispensed pursuant to a prescription. One of the two states I am licensed in, requires a monthly C-II inventory. The CVS system prompts you to count C-IIs every day. They pop up in QV. Not all get counted every day, of course. The ones that are slow movers pop up in QV just once a month. The fast movers pop up in QV several times a week It's down to the tablet and it is down to the mL. It is exact and it must match. The system knows what has been purchased vs. what has been dispensed and what should have been dispensed. If those don't match, of course, that will prompt an audit, likely an internal audit. Where are those bottles? You can't tell the auditor you did not want to waste those 90 mL each time. That's not a valid reason to anyone. Otherwise, how do you think an inventory is done? I'm curious now.

I've read plenty of disciplinary proceedings involving pharmacists who either underdispense or overdispense. Neither state board of pharmacy is keen on that. The Midwest is crackhead central. That won't fly here.

Best,

Apotheker2015

I feel like we're speaking two different languages. When I talk of being short on a controlled substance I mean a discrepancy between the Perpetual inventory and the actual amount on hand. My Perpetual inventory comes from the amount logged as being dispensed, not from the directions of use. I do not account for inventory based on the Sig of a prescription, I do it based on the amount dispensed. As does every other pharmacist in the world.

I don't even know how it would be possible to try to do an inventory based on the Sigs of all my prescriptions as you are suggesting.

How on Earth could the computer know that you have over dispensed by 90 ml's? It can't, it can only know that you have dispensed what you recorded as being dispensed.

You are not "short", you simply have a record of over dispensing. Notice that I'm not arguing this is how it should be done I'm only pointing out that your inventory will not be short. When prompted to do a count the amount on hand will match the Perpetual inventory as long as you have correctly recorded the amount dispensed.

Am I not being clear? Am I way out in left field? I feel like this is a simple concept lol

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[Apotheker2015]

If the script is as the OP says, "15ml qday, disp. 3 180ml bottles" then the quantity you should dispense is 540 ml. What's so hard about this? Why do you keep saying 450 ml? The script doesn't say "15ml qday x30 days." Even Florida law doesn't say that (from my brief search, maybe I'm wrong). There is no legal reason 3 180ml bottles can't be dispensed. No drug is being dispensed without a prescription.

Why can't a prescriber write for bottles? I see and fill all the time for 1 tube, 1 inhaler, 1 box, 1 whatever. If there is an issue with different sizes (30gm vs 80gm tube) then I call and clarify, but there is still nothing wrong with writing for a unit like that especially when they do specify the size.

15 mL/day x 30 days = 450 mL

If you can't see that, then I don't know what to tell you.

 

[doublehh03]

So

15 mL/day x 30 days = 450 mL

If you can't see that, then I don't know what to tell you.

Nowhere in the OP did the OP say it was for 30 days only. The conversation may have been veered in another direction with day supply or whatever but the issue isn't what was dispensed.

OP simply says 15ml qd dispense 3x180ml bottle. So if you work at CVS and you dispense 3x180ml = 540ml, the system would note that you dispensed 540ml, and thus deduct 540ml from inventory. This is basic math.

 

[Apotheker2015]

So


Nowhere in the OP did the OP say it was for 30 days only. The conversation may have been veered in another direction with day supply or whatever but the issue isn't what was dispensed.

OP simply says 15ml qd dispense 3x180ml bottle. So if you work at CVS and you dispense 3x180ml = 540ml, the system would note that you dispensed 540ml, and thus deduct 540ml from inventory. This is basic math.

You should not be dispensing 90 mL as a 30 day supply.

 

[Rockinacoustic]

15 mL/day x 30 days = 450 mL

If you can't see that, then I don't know what to tell you.

I assume your Lantus patient injecting 5 units daily gets an empty box then?

 

[Apotheker2015]

I assume your Lantus patient injecting 5 units daily gets an empty box then?

Once again... C-II suspension

 

[BenJammin]

15 mL/day x 30 days = 450 mL

If you can't see that, then I don't know what to tell you.

C2s are limited to 30 day supplies at the federal level so I don't accept the premise of your comment. If you don't want to break a bottle for insurance then just dispense two. This is the easiest problem to solve, not sure why you can't see the clear answer.

 

[Old Timer]

15 mL/day x 30 days = 450 mL

If you can't see that, then I don't know what to tell you.

You seem to be the only one in this thread stuck with the 30 day rule. It may apply in your state, but it does not apply in mine. The insurance may also limit you. Secondly, unless your state does C-II counts, the DEA will only look at the face of the rx and see 540 ml as there is no federal limit. So, you might have a problem with your state which would require you to dispense 360 ml and make them get a new rx. But that would be a state specific thing. I would never ever ever ever order 540ml and dispense only 450ml and leave the rest to go out of date and get no credit.

C2s are limited to 30 day supplies at the federal level so I don't accept the premise of your comment. If you don't want to break a bottle for insurance then just dispense two. This is the easiest problem to solve, not sure why you can't see the clear answer.

CII's are not limited at the Federal Level.

Schedule II controlled substances require a written prescription which must be manually signed by the practitioner or an electronic prescription that meets all DEA requirements for electronic prescriptions for controlled substances. There is no federal time limit within which a schedule II prescription must be filled after being signed by the practitioner. However, the pharmacist must determine that the prescription is still needed by the patient. While some states and many insurance carriers limit the quantity of controlled substances dispensed to a 30-day supply, there are no express federal limits with respect to the quantities of drugs dispensed via a prescription. However, the amount dispensed must be consistent with the requirement that a prescription for a controlled substance be issued only for a legitimate medical purpose by a practitioner acting in the usual course of professional practice. For a schedule II controlled substance, an oral order is only permitted in an emergency situation

http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_content.htm

 

[BenJammin]

C2s are not limited at the federal level. Left out the "not" lol. Without it, my comment makes no sense.

 

[BenJammin]

This kid is on the Quillivant XR 5mg/ml oral suspension, last month the rx was written for 15 ml q day, disp. three 180ml bottles. This month, the rx was written for the same suspension, but for 20 ml q day, disp. four bottles. Insurance obviously had issues with the dosage, but that's not the only issue. The kid's dad wants the script filled 9 days earlier than due date. He says "I know it is okay to fill, because the doctor has changed the directions from 15 ml to 20 ml, so it's a new prescription, and not a refill".

Seriously? He's obviously not concerned with his 11-year old developing tolerance to the drug and possibly be at risk for overdosing. I told him I needed a PA from the doctor to override the insurance block, but I am still not sure filling the script 9 days ahead of schedule is okay. Could someone please help clarify?

I encountered a similar issue with a tramadol script last week where the directions changed and the dosage went up from the previous month's fill, patient wanted the tramadol filled early due to the change, claiming that it is now no longer a refill, but a new script.

Since we seem to have no idea how to be a pharmacist, let me educate some people here. Throw out the dosage and tolerance question and look at the quantity and day supply issue. You dispensed a 36 day supply of medication and probably billed for a 30 day supply. That's okay with insurance because they do not expect you to throw out the rest of the stock bottle. The patient is getting an official dose increase but you didn't mention nor did you inquire about how long they have been taking the medication at the new and improved dose. This is why there is an early refill request. Clearly. Submit the PA to the doctor's office and once it is approved/denied, process the prescription.

Any argument that you're dispensing more than prescribed because a standard prescription is 30 days is not to be taken seriously. A physician in my state can write a 30 day C2, 35 day C2, 60 day C2, etc. No one is bringing up specific state limits on C2s so I don't see why we're having such a problem with an issue that has a clear answer from the feds.

 

[sosoo]

are u not comfortable saying no and refuse the script? does your company not tell u what to do when suspecting misuse of control substances? are u a drug dealer helping ppl abuse the meds, or helping ppl to better health?

 

[swatchgirl]

Since we seem to have no idea how to be a pharmacist, let me educate some people here. Throw out the dosage and tolerance question and look at the quantity and day supply issue. You dispensed a 36 day supply of medication and probably billed for a 30 day supply. That's okay with insurance because they do not expect you to throw out the rest of the stock bottle. The patient is getting an official dose increase but you didn't mention nor did you inquire about how long they have been taking the medication at the new and improved dose. This is why there is an early refill request. Clearly. Submit the PA to the doctor's office and once it is approved/denied, process the prescription.

Any argument that you're dispensing more than prescribed because a standard prescription is 30 days is not to be taken seriously. A physician in my state can write a 30 day C2, 35 day C2, 60 day C2, etc. No one is bringing up specific state limits on C2s so I don't see why we're having such a problem with an issue that has a clear answer from the feds.

I got it. Thank you.

 

[Apotheker2015]

C2s are limited to 30 day supplies at the federal level so I don't accept the premise of your comment. If you don't want to break a bottle for insurance then just dispense two. This is the easiest problem to solve, not sure why you can't see the clear answer.

You're taking one sentence out of 25 things that have been said. And just so you know, there are no federal limits on day supply or quantity that can be dispensed at one time. So I have no idea what you are saying. No response needed.

 

[BenJammin]

You're taking one sentence out of 25 things that have been said. And just so you know, there are no federal limits on day supply or quantity that can be dispensed at one time. So I have no idea what you are saying. No response needed.

Multiple posts have been made since that comment. Yes there are no federal limits as I have already stated. If you read above I actually describe why your comments have been total nonsense. It's quite astonishing how insane your comments here have been. There's no telling how many patients you've screwed over with the failed logic you have shown all of us here.

 

[Apotheker2015]

You seem to be the only one in this thread stuck with the 30 day rule. It may apply in your state, but it does not apply in mine. The insurance may also limit you. Secondly, unless your state does C-II counts, the DEA will only look at the face of the rx and see 540 ml as there is no federal limit. So, you might have a problem with your state which would require you to dispense 360 ml and make them get a new rx. But that would be a state specific thing. I would never ever ever ever order 540ml and dispense only 450ml and leave the rest to go out of date and get no credit.


CII's are not limited at the Federal Level.


http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_content.htm

Old Timer,

I am quite familiar with the manual, actually. I was doing the math for him. If you read my responses, you'd see I have not once said there is a 30 day rule. Not sure where you are getting that from. One of the two states I am in does do C-II counts, yes. I was simply doing the calculation for him to show that I would not dispense 540 mL as a 30 day supply since he kept talking about 540 mL and having no issue with dispensing an additional 90 mL; all as a 30 day supply. Or maybe that's not what he meant. Who knows? I am not going to go back and re-quote and all of that.
While I did say in an earlier response that there are some somethings that may steer you to dispense no more than a 30 day supply, I started by agreeing that there is no limit in quantity or day supply that can be dispensed. That's all.
It's been a good exchange, though. I think that the variability in responses shows that there are some gaps in communications and perhaps, we have not all stated the assumptions we are making or the specifics of each one's state law. My main issue was documenting 540 mL as a 30 day supply. That's that. Minus the jabs, though, I think that we've done a great job at illustrating how this could be handled in many different ways. It comes down to how we each choose to practice and who we work for and how they want you to practice. Yo (or anyone) may be OK with overdispensing. Plenty of people won't and that is OK. This is not a referendum. Regardless of how many people support one stance or another, we are each going to do as we see fit.

Best,

Apotheker2015

 

[Apotheker2015]

Multiple posts have been made since that comment. Yes there are no federal limits as I have already stated. If you read above I actually describe why your comments have been total nonsense. It's quite astonishing how insane your comments here have been. There's no telling how many patients you've screwed over with the failed logic you have shown all of us here.

BenJammin,

bud, missed the "no" you later added to your comment. Relax...

 

[Apotheker2015]

Multiple posts have been made since that comment. Yes there are no federal limits as I have already stated. If you read above I actually describe why your comments have been total nonsense. It's quite astonishing how insane your comments here have been. There's no telling how many patients you've screwed over with the failed logic you have shown all of us here.

Nothing that I have said shows that I have screwed over patients. My bottom line was that I would not dispense 540 mL as a 30 day supply as some suggested when I know that a 30 day supply of it is 450 mL. That's it. That hurts no one.

 

[Dr Wario]

I think almost the entirety of this tread is miscommunication.

 

[Apotheker2015]

I think almost the entirety of this tread is miscommunication.

YUP...

 

[BidingMyTime]

Th
is is the only right answer. Anything else is writing or speaking to hear yourself talk.

I do like this. LOL So, I must respond.

I think almost the entirety of this tread is miscommunication.

I think this is the most pertinent comment on this thread.

I am really surprised that this thread is so controversial in opinion.

Some states do have 30 day limits (IL does). I don't think the op ever stated whether or not there state had a 30 day limit, but I think we all agree, if there state has a 30 day limit, then they must limit to a 30 day supply, regardless of federal law having no limit.

Next, the high dosage is definitely to be questioned. But there are individual differences. I have seen patients on 30+mg of coumadin/day, 0.5mg+/500mcg+/levothyroxine/day, etc....scary levels, but their medical record showed that for these individual patients, these dosages were necessary. Now a high level of a CII in a minor child does beg the question of abuse by others in the household, and this is not easy to ascertain. But a high level could possibly be necessary in this child for a variety of reasons. I wouldn't fill this prescription without asking questions, but I also don't see any reason to outright refuse filling it without looking into the situation further.

Of course, the simplest answer to the OP, as has been stated.....find out when the dose was actually increased, figure out the days supply left from the previous prescription, then fill the new prescription at an appropriate time based on that.

Of course, you have the right to refuse to fill any prescription if you have "bad vibes" or whatnot.....but as a professional, its best to only refuse to fill the prescription when you have a legitimate reason not to refill it (or to delay refilling it until such and such a date.)

I don't know that I would agree with OldTimer in routinely changing the days supply for ins billing based on the package size.....but I think he is right in that as long as you are documenting, it shouldn't really be a problem. IE with the testosterone shortage some time back, when only 10ml vials were available.

 

[BenJammin]

Nothing that I have said shows that I have screwed over patients. My bottom line was that I would not dispense 540 mL as a 30 day supply as some suggested when I know that a 30 day supply of it is 450 mL. That's it. That hurts no one.

So if a 30 day supply for insurance is 3.5 insulin pens, are you giving an entire box or 3 pens and another one you empty out halfway?

 

[zelman]

So if a 30 day supply for insurance is 3.5 insulin pens, are you giving an entire box or 3 pens and another one you empty out halfway?

...or 3 pens?

 

[BenJammin]

...or 3 pens?

Then you're shorting the patient the amount the physician wrote for. Some people in this thread apparently think that we should pour out Quillivant if it doesn't conform to a 30 day supply.

 

[zelman]

Then you're shorting the patient the amount the physician wrote for. Some people in this thread apparently think that we should pour out Quillivant if it doesn't conform to a 30 day supply.

How are you shorting the patient? The insurance policy they signed up for has restrictions. I didn't decide that 1 day supplies cost the same as a 27 day supply and that 35 days wasn't covered at all.

 

[BidingMyTime]

So if a 30 day supply for insurance is 3.5 insulin pens, are you giving an entire box or 3 pens and another one you empty out halfway?

Patient's get full boxes only, and if they end up being "shorted" because their insulin only lasts 25 days and their insurance doesn't pay over 30 days, well that is how their insurance is set up, so they should take their complaints there.

However, insulin is completely different from a CII. The DEA isn't going to come after you for giving out extra insulin, they will if you are giving out extra Quillivant.

 

[Apotheker2015]

So if a 30 day supply for insurance is 3.5 insulin pens, are you giving an entire box or 3 pens and another one you empty out halfway?

I've already addressed this several times. I was referring specifically to a C-II suspension.

 

[Apotheker2015]

Patient's get full boxes only, and if they end up being "shorted" because their insulin only lasts 25 days and their insurance doesn't pay over 30 days, well that is how their insurance is set up, so they should take their complaints there.

However, insulin is completely different from a CII. The DEA isn't going to come after you for giving out extra insulin, they will if you are giving out extra Quillivant.

THANK YOU!!! That is what happens when someone starts scraping for threads to pull to "win" an argument. The thread is clearly about a C-II suspension.

 

[Old Timer]

I've already addressed this several times. I was referring specifically to a C-II suspension.

SO WHAT. The principal is the same. The doctor orders a box of insulin pens. Said pens are more than a 30 day supply. Do you split the package even though the boxes all say for single patient use only.

This is the same. Read the OP

This kid is on the Quillivant XR 5mg/ml oral suspension, last month the rx was written for 15 ml q day, disp. three 180ml bottles. This month, the rx was written for the same suspension, but for 20 ml q day, disp. four bottles.

So you have a legal order to dispense 540 ml. Now the only question is the billing. There is no DEA shortage, no Initial Notification to file for an inventory shortage. The question is and has always been how do you bill this? Give 360ml and bill for 24 day supply or bill for 540 and report it for 30 days with documentation on the hard copy that the package could not be split. I could see doing it both ways. I wouldn't have an issue with doing it either way.

 

[Dr Wario]

SO WHAT. The principal is the same. The doctor orders a box of insulin pens. Said pens are more than a 30 day supply. Do you split the package even though the boxes all say for single patient use only.

This is the same. Read the OP


So you have a legal order to dispense 540 ml. Now the only question is the billing. There is no DEA shortage, no Initial Notification to file for an inventory shortage. The question is and has always been how do you bill this? Give 360ml and bill for 24 day supply or bill for 540 and report it for 30 days with documentation on the hard copy that the package could not be split. I could see doing it both ways. I wouldn't have an issue with doing it either way.

I would probably give 3 x 150 ml bottles (for 15ml qd) and 4 x 150ml (for 20ml qd) and tell the pt the rest is void due to insurance limitations (do realize this drug comes in 60, 120, 150 and 180ml bottles).

 

[Old Timer]

I would probably give 3 x 150 ml bottles (for 15ml qd) and 4 x 150ml (for 20ml qd) and tell the pt the rest is void due to insurance limitations (do realize this drug comes in 60, 120, 150 and 180ml bottles).

I have no problem as long as the cost/ml is the same for each unit. Almost all third party contracts say you have to bill the largest package size or the most common package size.

 

[BenJammin]

However, insulin is completely different from a CII. The DEA isn't going to come after you for giving out extra insulin, they will if you are giving out extra Quillivant.

In the context of the original problem, there is absolutely no difference between insulin and a C2. The doctor ordered 3 bottles but insurance only pays for 30 days. You aren't giving them extra medicine, you're giving them exactly what was ordered. If you get a prescription for a bottle of insulin (10 ml), the directions add up to 7 ml used every 30 days, and insurance only pays for 30 days are you withdrawing 3 ml from the bottle?

Either there is some major miscommunication going on or some people here have no idea how to practice pharmacy. Never in my life have I been on the same side as Old Timer lol. That's how you know something weird is going on in this thread.

 

[Old Timer]

In the context of the original problem, there is absolutely no difference between insulin and a C2. The doctor ordered 3 bottles but insurance only pays for 30 days. You aren't giving them extra medicine, you're giving them exactly what was ordered. If you get a prescription for a bottle of insulin (10 ml), the directions add up to 7 ml used every 30 days, and insurance only pays for 30 days are you withdrawing 3 ml from the bottle?

Either there is some major miscommunication going on or some people here have no idea how to practice pharmacy. Never in my life have I been on the same side as Old Timer lol. That's how you know something weird is going on in this thread.

A stopped clock is right twice a day......

 

[BenJammin]

A stopped clock is right twice a day......

 

[zelman]

In the context of the original problem, there is absolutely no difference between insulin and a C2. The doctor ordered 3 bottles but insurance only pays for 30 days. You aren't giving them extra medicine, you're giving them exactly what was ordered. If you get a prescription for a bottle of insulin (10 ml), the directions add up to 7 ml used every 30 days, and insurance only pays for 30 days are you withdrawing 3 ml from the bottle?

Either there is some major miscommunication going on or some people here have no idea how to practice pharmacy. Never in my life have I been on the same side as Old Timer lol. That's how you know something weird is going on in this thread.

I order the three mL size if it's a Lilly product and dispense 6 mL.