Mail order pharmacy

[ZakMeister]

So the other day, we had a patient who regularly gets her lisinopril from mail order but for some reason the order was gonna arrive late for her next fill. She came in to our store to ask if she cud get enuf to last till her order arrives in 3/4 days. My RPh was a floater n turned away. Should he have done that? He was like even if she got a new script from doc for those days the insurance would reject as duplicate?

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[PharmacistReb]

I worked independent pharmacy for years and we would fill the bottle with 5 days worth and charge them a little over cost. Especially since it was typically elderly people who were in dire straits and truly needed help.

That's where ethics trumps legality. No Board of Pharmacy is going to screw you for giving an 80 year old lady five lisinopril 40mg tablets.

 

[rxmommy7]

Who cares if insurance will reject? Get a new rx and charge her cash price for a couple of tablets. Happens all the time. If you're helpful and understanding, when it happens a few times in a row they switch back to your store. I've seen that happen many times.

 

[SClENCE]

I'd only give somebody a few days supply without a prescription if they always filled the med at my pharmacy. If she was willing to call her doctor and have a new script sent in I'd fill a few days worth for cash (or if she had an existing script in our system). I'm not going to hand out pills to people when I don't even have record of them even being on the med or the script on file is expired.

 

[owlegrad]

Most insurances will approve a bridge supply, if the pharmacist is so intent on not giving it away. For 5 lisinoprils I would have just given her enough to last the five days.

 

[trailerpark]

I would have given her a few only if she called her doctor and asked for a 5 day supply to be sent over. Without a rx she can kick rocks. What if she got angioedema, died then it was found out she got the pills from a pharmacy without a prescription and no record of filling there. Lawsuit

 

[trailerpark]

If it was an emergency med then that's why they have these special rooms for emergencies called ERs. I've had people come to my store wanting insulin and inhalers and their regular pharmacy was closed and they thought we would just give it to them.

 

[Ackj]

Most insurances will approve a bridge supply, if the pharmacist is so intent on not giving it away. For 5 lisinoprils I would have just given her enough to last the five days.

No way am I going through all of the hassle arguing with the insurance for an override ("yes, I KNOW the patient is mandatory mail order..." ) to get reimbursed 9 cents for 5 lisinopril. That's getting cashed out if they want the rx.

 

[josh6718]

So the other day, we had a patient who regularly gets her lisinopril from mail order but for some reason the order was gonna arrive late for her next fill. She came in to our store to ask if she cud get enuf to last till her order arrives in 3/4 days. My RPh was a floater n turned away. Should he have done that? He was like even if she got a new script from doc for those days the insurance would reject as duplicate?

The insurance probably would reject it, though like others have said a call to the insurance will nearly always provide an override.

The being said, I would never give/'loan' out any drugs I do not have have a prescription for at my pharmacy (even if it is a bottle from a mail order).

If they need it, a call to the doctor for a prescription and filling it for a weeks worth makes most sense.

 

[PharmacistReb]

A 90 year old visiting her children brings in an empty bottle of hydralazine 25 TID from her mail order on a Saturday morning and says she needs some because her blood pressure is very high and she hasn't had any in 24 hours and you tell her to kick rocks or go to the ER?

That is the most impractical thing I've ever heard. Even if it's lisinopril, are you genuinely going to worry about angioedema and tell her to shove off?

I'm not about to hand out Flexeril or Claritin but if someone comes in with a legitimate chronic medication and I'm working a Saturday morning, telling them to find a way to contact their doctor in real time or go to the ER is so outside the scope of good pharmacy practice. You're a vending machine at that point that tells someone they don't have enough quarters.

I know CVS pharmacists are known for letting people fall out in the floor with asthma attacks or anaphylaxis because a scrip wasn't available. Are you guys corporate drones?

 

[M0df]

As far as CVS, with me it is the opposite. As long as there is proof of patient taking that medication, I don't have any problems giving a couple tablets. If anything at CVS, most pharmacists would want to avoid getting a call from corporate or your boss over this. I am also not a big fan of wasting 30 minute of my time over few tablets of dirt cheap generic.

 

[midweststudent1]

Why in the world wouldn't you get a script and just charge 3.99 and give her a whole 30 day supply. That opens up the opportunity to transfer all her scripts to the pharmacy

 

[PharmacistReb]

Why in the world wouldn't you get a script and just charge 3.99 and give her a whole 30 day supply. That opens up the opportunity to transfer all her scripts to the pharmacy

So you charge her a cash price for a medication that is dirt cheap and then she thinks all of your prices are going to be dollar-store cheap? -- and they're not. Then she brings in a prescription for 90 days of Tradjenta and her insurance rejects it and mandates she only get 30 unless she uses mail order. Then she gets pissed off because her mail order was allowing her to get 90 days and at cheaper price proportional to the 30 day copay she'll pay in a store.

Next, if you're working for anybody that's not a chain, you're not going to attempt to win her over with cheap cash prices. In the independent world, the cash prices are where we can really make some money. People come to us for convenience and no time waiting. You do not want to get into a bidding war with cash prices or advertise that you're somehow going to beat the mail order with prices.

Third, a great number of people who travel will come in with this problem. Aside from just a local mail order patient, there are many people who will come in with a mail order bottle and the occasional person who has an independent pharmacy back home that's not open when they bring you the bottle. Trying to market your store is always good but the most practical thing is selling them a 5 day supply for a dollar or two.

I've never heard a pharmacist tell a patient to "kick rocks" or "go to the ER". First of all, your state Board of Pharmacy is not going to do anything to you for giving a non-controlled chronic medication for blood pressure/diabetes/seizure/etc to someone who needs it. Secondly, there is a much higher propensity that this person's condition worsens as a result of not doing anything as opposed to some litigious incident where they take it and have angioedema.

 

[midweststudent1]

So you charge her a cash price for a medication that is dirt cheap and then she thinks all of your prices are going to be dollar-store cheap? -- and they're not. Then she brings in a prescription for 90 days of Tradjenta and her insurance rejects it and mandates she only get 30 unless she uses mail order. Then she gets pissed off because her mail order was allowing her to get 90 days and at cheaper price proportional to the 30 day copay she'll pay in a store.

Next, if you're working for anybody that's not a chain, you're not going to attempt to win her over with cheap cash prices. In the independent world, the cash prices are where we can really make some money. People come to us for convenience and no time waiting. You do not want to get into a bidding war with cash prices or advertise that you're somehow going to beat the mail order with prices.

Third, a great number of people who travel will come in with this problem. Aside from just a local mail order patient, there are many people who will come in with a mail order bottle and the occasional person who has an independent pharmacy back home that's not open when they bring you the bottle. Trying to market your store is always good but the most practical thing is selling them a 5 day supply for a dollar or two.

I've never heard a pharmacist tell a patient to "kick rocks" or "go to the ER". First of all, your state Board of Pharmacy is not going to do anything to you for giving a non-controlled chronic medication for blood pressure/diabetes/seizure/etc to someone who needs it. Secondly, there is a much higher propensity that this person's condition worsens as a result of not doing anything as opposed to some litigious incident where they take it and have angioedema.

I worked for an independent that was very successful for several years. We gained many patients with a lot of rxs by "winning them over" be it with going the extra mile or giving them great cash prices on generics. If you bail them out of a real problem or two, they won't care that they can only get a 30 day supply from you, they'll still come to you. Most people with chronic problems want the pharmacist to know them by name and be able to answer their questions when they come up.

 

[SClENCE]

A lot of these situations could be avoided if the patient took responsibility for their health. Is it really an emergency or did you just fail to plan ahead and want the pharmacy to bail you out?

 

[hurx]

A lot of these situations could be avoided if the patient took responsibility for their health. Is it really an emergency or did you just fail to plan ahead and want the pharmacy to bail you out?

I'm not giving her pills without a prescription. I will do my best to reach her doctor/the mail order pharmacy but if not...

And some patients can be very dramatic. Like the patient who hadn't filled her lisinopril script in 5+ months but wanted a refill now. "Sorry ma'am, your prescription is expired. You'll have to get a new one from the doctor." "So you're just gonna let me die?!"

 

[Vain Brother]

A 90 year old visiting her children brings in an empty bottle of hydralazine 25 TID from her mail order on a Saturday morning and says she needs some because her blood pressure is very high and she hasn't had any in 24 hours and you tell her to kick rocks or go to the ER?

That is the most impractical thing I've ever heard. Even if it's lisinopril, are you genuinely going to worry about angioedema and tell her to shove off?

I'm not about to hand out Flexeril or Claritin but if someone comes in with a legitimate chronic medication and I'm working a Saturday morning, telling them to find a way to contact their doctor in real time or go to the ER is so outside the scope of good pharmacy practice. You're a vending machine at that point that tells someone they don't have enough quarters.

I know CVS pharmacists are known for letting people fall out in the floor with asthma attacks or anaphylaxis because a scrip wasn't available. Are you guys corporate drones?

Claritin?

agreed though

 

[PharmacistReb]

A lot of these situations could be avoided if the patient took responsibility for their health. Is it really an emergency or did you just fail to plan ahead and want the pharmacy to bail you out?

So a patient with dementia comes in and his/her son or daughter brings me an empty mail order bottle that the mail order company has failed to send on time. I'm supposed to look at these people and tell them that the patient needs to take more responsibility for herself?

What's it like to not live in the real world and be an asshat generally to everyone with no regard to certain situational occurrences? I hope you are in the minority of pharmacists that behave this way.

 

[ZakMeister]

So a patient with dementia comes in and his/her son or daughter brings me an empty mail order bottle that the mail order company has failed to send on time. I'm supposed to look at these people and tell them that the patient needs to take more responsibility for herself?

What's it like to not live in the real world and be an asshat generally to everyone with no regard to certain situational occurrences? I hope you are in the minority of pharmacists that behave this way.

Some people can take advantage of the generosity pharmacists bestow upon them, I guess charging them for tad bit of pills will make both parties happy.

 

[PharmacistReb]

Science, it says you're a pharmacy student. I don't know what your experience is in pharmacy. I spent 3 years in a very poor, underserved area of Kentucky. Our patient population was eldery and poor with a large minority population. Working in a lower socioeconomical area of the country provides an unbelievable ability to understand how drug seekers work and to know when to turn someone away and when to take a stand. When it comes to scheduled medications, there should never be an instance where one thinks it's ok to "bend" the rules out of convenience. So that's not the issue at hand here.

But when you work in a small community and people know you as the pharmacist and they trust that you're there to advance their health, you do not turn away a patient for a chronic medication especially if its no fault of their own. Not only do you cause potential health problems with that person if they're unable to obtain the medications that were never delivered, but you start to create doubt and negative feelings in the community about how you run your store. We had a Catholic priest who was a pillar of the community -- service oriented, loved by everyone, all-around good guy -- who frequented our pharmacy. If he had brought his ailing mother or father into my store with an empty mail order bottle for lisinopril and I turned him away, I would lose credibility instantly with him and whoever saw me do this. And a ripple effect where if you make this the norm, people think you're following the letter of the law but you're careless in your approach to helping people. And in a small southern community, it does not take long for a member of the local health care team to have their reputation tainted. It's not as if someone is asking you for Ambien or Norco or Restoril. I told people, young and old, that I could not loan out controlled medications under any circumstance. But you're not living within the confines of reality, particularly in small town retail, if you think it's a practical practice to turn away elderly people who's mail order company has screwed them over or even if they've forgotten to renew their order.

Nobody on your state Board of Pharmacy is going to say to turn away someone on a late weekend afternoon because they can't contact their doctor for a new prescription. This is just not how anyone should practice and it's not good for the patient's health -- the priority of all pharmacists.

 

[Vain Brother]

A lot of these situations could be avoided if the patient took responsibility for their health. Is it really an emergency or did you just fail to plan ahead and want the pharmacy to bail you out?

you're really bad at this empathy thing. as a retail pharmacist you're getting paid 60/hr for a job that is not terribly intellectually taxing, the least we can do is help people solve some of their problems without being openly judgmental, even if they might be self-inflicted.

you're a student. drop the pompous jadedness. it's not a great look

 

[npage148]

If I don't have or can't get a valid rx via the md or transfer I'm not going to give you pills. Do some leg work and get me a valid rx and I will help you out. I have told people to go to urgent care to get a valid rx for something trivial.

I don't have time or effort to help someone I don't know and will never see again for 1-2 scripts that will net my store <2$ and are necessary to me making plan. You're not going to win them over. They go to mail-order because they have to or only care about saving money so short of me paying them to come to my pharmacy they won't.

The absolute worst people are the ones that should have been out for months yet claim they ran out yesterday and throw a fit about dying. Your compliance is likd 52%, you're not going to die now if you haven't yet

 

[PharmacistReb]

If I don't have or can't get a valid rx via the md or transfer I'm not going to give you pills. Do some leg work and get me a valid rx and I will help you out. I have told people to go to urgent care to get a valid rx for something trivial.

I don't have time or effort to help someone I don't know and will never see again for 1-2 scripts that will net my store <2$ and are necessary to me making plan. You're not going to win them over. They go to mail-order because they have to or only care about saving money so short of me paying them to come to my pharmacy they won't.

The absolute worst people are the ones that should have been out for months yet claim they ran out yesterday and throw a fit about dying. Your compliance is likd 52%, you're not going to die now if you haven't yet

All of my examples totally ignored. Everyone's response that is in favor of NOT giving someone the pills validates their argument by calling that individual lazy or careless. In these responses, there never exists a situation where it's a weekend and the mail order hasn't gotten to someone's house yet and they are totally screwed. Imagine your grandmother not getting her mail order and it's late Saturday afternoon and her physician is nowhere to be found. And then imagine the pharmacist telling her that she needs to find the nearest urgent care, wait in the waiting room for an hour, get a prescription, and then return to said pharmacy so that he can legally fill her medications. Then imagine that you're in the rural south like me and the nearest urgent care is sometimes 30 minutes away. So you tell this elderly woman to drive 60 miles round trip to the nearest urgent care so she can retrieve a prescription to bring back to you. Then imagine your store closes in thirty minutes. And closed on Sunday's. All of these are real situations. And all of you asshats would rather tell this poor soul to f*** off. Great group we got here.

 

[Dred Pirate]

a couple of points (I used to moonlight retail - but predominately hospital career)
1. DO NOT send them to my ER because they ran out of medications unless it is an absolutely last resort. They can call their MD - somebody should be oncall for them, if that fails, go to URGENT care first, it is MUCH cheaper and MUCH more appropriate.
2. There are two types of people that this happens to - those they are just ignorant and have the ability to take care of themselves, and those that for whatever reason don't (elderly, demented, etc)
3. If you don't have a record of rx's for them (meaning they are not your patient) you do have the potential for liability. There was a sting once where members of the board of pharmacy went around with emtpy rx bottles begging for a refill using this story and then proceeded to file charges if they filled it - complete BS - but it can happen
4. They have the ability to get a RX - charge them cash if it is a cheap med, it is an expensive med, offer them cash, or process with ins with override

 

[ZakMeister]

a couple of points (I used to moonlight retail - but predominately hospital career)
1. DO NOT send them to my ER because they ran out of medications unless it is an absolutely last resort. They can call their MD - somebody should be oncall for them, if that fails, go to URGENT care first, it is MUCH cheaper and MUCH more appropriate.
2. There are two types of people that this happens to - those they are just ignorant and have the ability to take care of themselves, and those that for whatever reason don't (elderly, demented, etc)
3. If you don't have a record of rx's for them (meaning they are not your patient) you do have the potential for liability. There was a sting once where members of the board of pharmacy went around with emtpy rx bottles begging for a refill using this story and then proceeded to file charges if they filled it - complete BS - but it can happen
4. They have the ability to get a RX - charge them cash if it is a cheap med, it is an expensive med, offer them cash, or process with ins with override

What did you mean by offering cash? Also if you get an override from the insurance, will it automatically adjust the discrepancy on their next fill?

 

[Dred Pirate]

What did you mean by offering cash? Also if you get an override from the insurance, will it automatically adjust the discrepancy on their next fill?

offer them the cash price
I really doubt it adjusts any discrepenacy

 

[npage148]

Imagine your grandmother not getting her mail order and it's late Saturday afternoon and her physician is nowhere to be found. And then imagine the pharmacist telling her that she needs to find the nearest urgent care, wait in the waiting room for an hour, get a prescription, and then return to said pharmacy so that he can legally fill her medications. Then imagine that you're in the rural south like me and the nearest urgent care is sometimes 30 minutes away. So you tell this elderly woman to drive 60 miles round trip to the nearest urgent care so she can retrieve a prescription to bring back to you. Then imagine your store closes in thirty minutes. And closed on Sunday's. All of these are real situations. And all of you asshats would rather tell this poor soul to f*** off. Great group we got here.

My grandparents were more reposible than that. But my real sticking point is name a drug used in retail that is so critical that a patient will be harmed if they go a weekend without. Insulin, sure, but are you handing out or selling vials of insulin to these patients? Actually non-analog insulin is OTC so that's not an issue. You can miss 1-2 day of just about all outpatient medication without problem

 

[owlegrad]

My grandparents were more reposible than that. But my real sticking point is name a drug used in retail that is so critical that a patient will be harmed if they go a weekend without. Insulin, sure, but are you handing out or selling vials of insulin to these patients? Actually non-analog insulin is OTC so that's not an issue. You can miss 1-2 day of just about all outpatient medication without problem

Warfarin comes to mind. Digoxin. Psychiatric meds. Of course if they have a stroke/become suicidal they can go to an ER, so I guess it isn't really an "emergency" just yet.

 

[owlegrad]

There was a sting once where members of the board of pharmacy went around with emtpy rx bottles begging for a refill using this story and then proceeded to file charges if they filled it - complete BS - but it can happen

Of course this may very by state law, but my state allows for a few days supply of maintenance meds to be given to patients if needed. Last time we had this conversation I don't think anyone found a state that didn't have something in their pharmacy practice laws to this effect. So, which state had this sting?

 

[PharmacistReb]

My grandparents were more reposible than that. But my real sticking point is name a drug used in retail that is so critical that a patient will be harmed if they go a weekend without. Insulin, sure, but are you handing out or selling vials of insulin to these patients? Actually non-analog insulin is OTC so that's not an issue. You can miss 1-2 day of just about all outpatient medication without problem

Again, this very commonly has nothing to do with the responsibility of the person. This is very commonly an issue where mail order did not send the medication on time and the patient has run out. I worked independent retail for three years and this happened about a once a week with an elderly member of our community. And this was not uncommon for it to happen on a weekend. They do not know pharmacy law and do not care about your sanctimonious stands on such laws. These people come in to a community pharmacy on a late Saturday afternoon in a city that has no ER or an urgent care (the town I worked has neither) with an empty bottle of hydrazine 50mg three-four times daily that they just ran out of. They don't have that evening's dose and missed the afternoon dose and there is no local place to go. They just checked their blood pressure and they tell me the "top number was 170". Are you going to tell them to go the weekend without it or are you going to make the moral decision? I would always make them bring in their bottle from mail order. I would never fill it without some sort of verification that they actually took what they claimed they needed. But it's asinine to insist that only insulin is of critical importance to people in the retail setting.

In regard to this so-called "sting" with a Board of Pharmacy. I would for you to post the article or at least something that references this. Because I cannot fathom a BOP doing this unless it was controlled medications they were seeking. Why would a BOP go around, and as you state have the police "charge" them, over a couple lisinoprils. I do not, for one second, believe that a BOP was involved in a sting of non-controlled medications in which they impersonated patients asking for medications in such dire circumstances. I'm led to believe you're likely excluding some very valuable information to this story.

 

[PharmacistReb]

"You can miss 1-2 day of just about all outpatient medication without problem"

Good mindset to have here. Tell grandma visiting from out of state that she's unlikely to have a stroke and die and to just wait till Monday.

 

[GodsSon2011]

that floater is a douce bag. Give her the 5 pills so she can be out her way. If this was a pattern then I can understand a little. 5 pills is not even worth any drama

 

[SClENCE]

So a patient with dementia comes in and his/her son or daughter brings me an empty mail order bottle that the mail order company has failed to send on time. I'm supposed to look at these people and tell them that the patient needs to take more responsibility for herself?

What's it like to not live in the real world and be an asshat generally to everyone with no regard to certain situational occurrences? I hope you are in the minority of pharmacists that behave this way.

I said "A lot of these situations". Not "Every situation". But I expected some asshat to respond with a situation such as this. My point is that I am not going to hand out maintenance meds to random people with no record of the patient being on the med in the name of customer service.

 

[HelpfulPharmer1]

In the spirit of exploring ways to help patient and still protect our legal license, what do you think about this option:
I would call some doctors I know and explain the situation and hope that the doctor will REFILL the script out of compassion even though doctor never met this patient. Since this is refill, the law may allow doctor to refill (or may not.)

I don't know the answer so I am asking all to please share your knowledge. Thank you very much.

 

[PharmacistReb]

I said "A lot of these situations". Not "Every situation". But I expected some asshat to respond with a situation such as this. My point is that I am not going to hand out maintenance meds to random people with no record of the patient being on the med in the name of customer service.

In "a lot of these situations", patients who are on mail order are being hosed.

It's one thing to have a patient let his prescription expire or have no refills and them come in and expect it to be filled. That irks me to no end. In that regard, I will agree with you that it's best to let them know that there's nothing you can do and to start paying attention to expiration dates and refills. But with regard to mail order, it is typically the mail order company that is putting the patient in a tough position and it's no fault of his or her own. And with all the cynicism that we begin to develop towards the lazy patients, it's always good to keep in mind that some of these people genuinely need us to go out of our way in situations like this.