MD guide to RPh

[sozme]

Was reading this post on the Angry Pharmacist website. It got me thinking. I am not a pharmacist myself, but a 4th year medical student (who worked as a pharmacy technician for several years prior to med school). I was curious as to what SDN pharmacy forums prescribing tips would be to make life easier overall for the retail pharmacist. Perhaps we can get a repository of tips...

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[Rukn]

Don't write for stuff that doesn't exist

Don't forget to write everything on the script ... you don't know how annoying it is to call for stuff like quantity or directions or something

Please make your handwriting legible

When sending e scripts please try and make it make sense

Dont send stuff that should be filled at medical supply stores

 

[bp2313]

Plz don't ever tell the patients "it should be on the $4 list or it's generic, therefore costs only $0.01."

 

[Rukn]

And stop telling them it should be ready by the time you get there

 

[Dr Wario]

As a young doc I doubt you will have issues with this, but for god sake there is absolutely zero reason why any script should ever be called into a pharmacy instead of e-scribed. When there is a mistake on a phone-in, it adds liability both to you as the prescriber and to me as the pharmacist (and let's be honest, how much do you really trust that MA who can't pronounce Phenytoin with your license?).

Oh and also don't prescribe 4.763ml of amoxicillin 400/5 bid, it just makes you look stupid.

 

[cbrons]

I did have a question about this part from OP link-->

Allow us to substitute in the same class: Unless there is some HUGE issue with dispensing Aciphex instead of Protonix, please write “OK to substitute per formulary” on Rx’s that you write.

Can you actually do this?

 

[RxPreceptor]

I did have a question about this part from OP link-->

Can you actually do this?

Yes, I love when prescribers do this...makes life so easy in terms of insurance coverage. If you do e-scribing, put it in the MD notes section...there are many, many dose equivalencies for many classes of meds

 

[Lnsean]

I did have a question about this part from OP link-->

Can you actually do this?

I get scripts like that sometimes from the ER near my place. MD would right for "Ciprodex" and then at the bottom would write "can sub for cortisporin if ciprodex not covered. same sig."

 

[ldiot]

-If you eScribe something like Keflex 1 TID #14 write the day supply as 5 in the notes so we don't call thinking you screwed up the quantity
-Stop calling nebulizers and shower benches into CVS
-If you name is not preprinted on the script write out your first and last name because nobody can read your signature and we really don't want to call you to ask your name
-Include an ICD-10 on all Medicare part B scripts and realize that we can't take the ICD-10 over the phone. Writing "diabetes" on the script is not sufficient for Medicare...
-Stop telling the patient the script will be ready when they get to the pharmacy and don't try to guess the price
-If the patient is stable on a chronic med write it for a 90 days supply. We can always change it to 30 but we can't change a 30 to a 90. Some insurance plans require 90 and some patients prefer 90
-Write albuterol inhaler instead of just writing ProAir that way we aren't breaking a law when we switch it to Ventolin
-If we send a prior auth request don't just resend the same script
-If you up the dose of a med send a new script; don't just tell them to take more. Insurance won't cover it when they are trying to refill it 2 weeks early

 

[cbrons]

Yes, I love when prescribers do this...makes life so easy in terms of insurance coverage. If you do e-scribing, put it in the MD notes section...there are many, many dose equivalencies for many classes of meds

What exactly do you write in the sig? "substitute within class as necessary?"

 

[ldiot]

What exactly do you write in the sig? "substitute within class as necessary?"

I've never seen a doctor write that but I've seen them list anywhere from 1-3 alternate drugs. Usually with eye drops

 

[Rukn]

What exactly do you write in the sig? "substitute within class as necessary?"

seem em write stuff like "can use any prenatal that's covered " in the comments on e scripts

 

[rph3664]

I did have a question about this part from OP link-->

Can you actually do this?

Hospital pharmacists can, and do.

 

[rph3664]

I get scripts like that sometimes from the ER near my place. MD would right for "Ciprodex" and then at the bottom would write "can sub for cortisporin if ciprodex not covered. same sig."

That's the thing. They specified what they wanted if the first choice wasn't covered or available. It's another story when they don't do that.

 

[RxAddyCt]

Please write out directions clearly on the prescriptions. Do not simply just jot down "Take as directed" unless the manufacturer has directions printed on the drug itself (i.e. zpak, medrol dosepak, etc.).


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[DrNyvia]

What exactly do you write in the sig? "substitute within class as necessary?"

Many prescription pads have the "OK to substitute" section that you can sign on. If you don't, can write "OK to substitute."

 

[cbrons]

Many prescription pads have the "OK to substitute" section that you can sign on. If you don't, can write "OK to substitute."

I thought that meant subbing the brand name for generic

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[DrNyvia]

I thought that meant subbing the brand name for generic

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There's two types of substitutions: generic substitutions (brand to generic) and therapeutic substitutions (medication previously determined to be therapeutically equivalent to a second drug, even though it is not chemically identical to the prescribed drug). "OK to substitute" covers both if you are okay with that. Some prescription pads also specify whether they just want to allow generic substitution or not. Either way, consult with the prescriber of your changes.

 

[ldiot]

There's two types of substitutions: generic substitutions (brand to generic) and therapeutic substitutions (medication previously determined to be therapeutically equivalent to a second drug, even though it is not chemically identical to the prescribed drug). "OK to substitute" covers both if you are okay with that. Some prescription pads also specify whether they just want to allow generic substitution or not.

So you're telling me that a script for Nexium 40mg with "Substitution permissible" on it means that I can dispense not only generic but also, say, omeprazole 40mg if I want? I've always treated is as meaning generic is allowed and from what I have observed that's how everyone else interprets it.

The only type I actually substitute is when they write which specific drugs can be used or in the cases where they just write "prenatal" or something in which case I give them whatever I have the most of on the shelf.

 

[owlegrad]

There's two types of substitutions: generic substitutions (brand to generic) and therapeutic substitutions (medication previously determined to be therapeutically equivalent to a second drug, even though it is not chemically identical to the prescribed drug). "OK to substitute" covers both if you are okay with that. Some prescription pads also specify whether they just want to allow generic substitution or not.

I don't think any Board of Pharmacy is going to have your back on this one.

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[confettiflyer]

Get to know your hospital's formulary, and build relationships with your unit and central pharmacists...if not explicitly authorized by hospital policies and protocols, empower them with the ability to finesse your orders for operational and clinical efficiency.

Examples: renal adjustments (often already covered by existing policy), rounding home medications to what's available, random things like what form of vitamin D to give (mostly: whatever we have on formulary), just fix your dups, etc.

Basically, empower us and cut down on stupid phone calls we HAVE to call about until we figure you out, that way you spend more time being a physician and less time playing "call back the pharmacy to say yes"


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[confettiflyer]

I agree. I think that he's incorrect.

Agreed...but it'd be great in the comments if a doc writes "OK to sub any covered PPI" that's pretty much a blank check for the Rph to use their brain and act accordingly in a legal way.

Substitution permissible is brand/generic as we've reached a consensus on that part.


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[gwarm01]

Agreed...but it'd be great in the comments if a doc writes "OK to sub any covered PPI" that's pretty much a blank check for the Rph to use their brain and act accordingly in a legal way.

Substitution permissible is brand/generic as we've reached a consensus on that part.


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My favorite thing about my weekend job is that the authority to sub meds or handle duplicate therapy has been granted and is baked into the order comments. I almost never have to call unless there's an actual clinical issue.

 

[cbrons]

great thread boys

 

[DrNyvia]

Let me clarify. The drug does not need to be AB rated to substitute, but therapeutically equivalent (same generic) as determined by the pharmacist's professional opinion. This might be different depending on your state. From my state's Board of Pharmacy:

"2)Except as limited by subsections (3) and (5) of this section, unless the purchaser instructs otherwise, a pharmacist may substitute as follows:

(a)A drug product with the same generic name in the same strength, quantity, dose and dosage form as the prescribed drug which is, in the pharmacists professional opinion, therapeutically equivalent.

(b)When the prescriber is not reasonably available for consultation and the prescribed drug does not utilize a unique delivery system technology, an oral tablet, capsule or liquid form of the prescribed drug so long as the form dispensed or administered has the same strength, dose and dose schedule and is therapeutically equivalent to the drug prescribed."

 

[DrNyvia]

Now I believe "OK to substitute" covers all of the above.

 

[cbrons]

So you cant write Rxs for BP machines and tooth paste?

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[ldiot]

So you cant write Rxs for BP machines and tooth paste?

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I've seen doctors write "BP monitor" pretty often which is nice that we can give them whatever is covered, though most insurance don't cover any of them anyways so they might as well not have a script

What is usually more helpful is for diabetics when they just write meter, test scripts and lancets instead of specifying a specific brand that may not be covered, though a majority don't do this

 

[sozme]

Great thread.... I hope there are more contributions.

I remember working at national retailer for several years as a pharmacy tech... fairly busy pharmacy too...

One question I did have though... Has e-prescribing made your job easier or harder overall? I would think easier, because there is little to no handwriting interpretation to be done. On the other hand, people probably expect their stuff to be filled by the time they get there, and I am sure that extremely annoying, especially since they are sometimes sent via e-Scribe right when we close the patient encounter, which might be 5 minutes after the appointment is over.

 

[ldiot]

Great thread.... I hope there are more contributions.

I remember working at national retailer for several years as a pharmacy tech... fairly busy pharmacy too...

One question I did have though... Has e-prescribing made your job easier or harder overall? I would think easier, because there is little to no handwriting interpretation to be done. On the other hand, people probably expect their stuff to be filled by the time they get there, and I am sure that extremely annoying, especially since they are sometimes sent via e-Scribe right when we close the patient encounter, which might be 5 minutes after the appointment is over.

I like eScrips a lot more. It takes half the time to type up and no handwriting issues. Faxes I have to spend a few more seconds finding the patients, zooming in to read the script, and with a lot of eScripts some of the data fields are automatically translated over to our system. Hard copies are even worse because there is obviously no chance it will be done when the patient arrives and you also have to scan the image; just more steps and they usually want to wait on it. Just more interaction with the customer which takes more time.

 

[NaOH]

Escripts are a mixed bag. We see plenty of wonky, incorrect orders that sometimes get past us simply because they 'look' nice and neat and correct.


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[BidingMyTime]

I thought that meant subbing the brand name for generic
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It does, I'm not sure what the other poster is talking about. Pretty sure in most states (if not all) it is illegal to therapeutically substitute a drug, unless there is already an agreement between the provider and the pharmacy (such as in hospitals or HMO operated retail stores.) A general pharmacy can NOT legally therapeutically substitute, even if the doctor wrote "OK to substitute therapeutic equivalent", the pharmacy would still have to call to get an OK.

A for BP monitors and toothpaste, you can write a prescription for anything you want to, just do NOT tell the patient that it will be covered by insurance, because most of the time it won't be. Actually, do NOT tell the patient that anything will be covered by their insurance, unless you have actually called their insurance, submitted whatever PA is needed, and know for sure that it is covered.

 

[confettiflyer]

even if the doctor wrote "OK to substitute therapeutic equivalent", the pharmacy would still have to call to get an OK.

Really, you'd call on that one? Maybe I'm thinking if the provider was specific like "Any covered PPI at therapeutically equivalent dose" I would totally just write the script out as a new verbal order and forget about bugging the doc.

I'm leaning along the lines of...we're tasked with interpreting prescriber intent.

But I suppose "therapeutically equivalent " could even mean drugs outside of that class (like how Pepcid and Protonix are therapeutically equivalent in terms of SUP prophy in vented patients), so I suppose a phone call is in order there.


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[Sine Cura]

One question I did have though... Has e-prescribing made your job easier or harder overall? I would think easier, because there is little to no handwriting interpretation to be done. On the other hand, people probably expect their stuff to be filled by the time they get there, and I am sure that extremely annoying, especially since they are sometimes sent via e-Scribe right when we close the patient encounter, which might be 5 minutes after the appointment is over.

I hate e-scripts because it is that much more annoying to deny controls, especially C2s. There are a lot of docs who don't give a **** that their patients managed to piece together a holy trinity from multiple prescribers and go to multiple pharmacies, or go to the ED all the time despite being "managed" by a pain clinic.

More commonly are basic errors like orders for nonsensical quantities like 4 mL versus 4 oz, entering the wrong formulation of a CII that is never covered by an insurance plan when they normally get the one that is covered, so the patient gets pissed off because the medical assistant putting in the order ****ed up, or entering quantity 30 for a 15 day supply, or even quantity zero. Even better, you call to get the correction approved but they never fix the error on their end, which you can tell by the next time they send an order with the same goddamn error.

 

[Niosh]

Let me clarify. The drug does not need to be AB rated to substitute, but therapeutically equivalent (same generic) as determined by the pharmacist's professional opinion. This might be different depending on your state. From my state's Board of Pharmacy:

"2)Except as limited by subsections (3) and (5) of this section, unless the purchaser instructs otherwise, a pharmacist may substitute as follows:

(a)A drug product with the same generic name in the same strength, quantity, dose and dosage form as the prescribed drug which is, in the pharmacists professional opinion, therapeutically equivalent.

(b)When the prescriber is not reasonably available for consultation and the prescribed drug does not utilize a unique delivery system technology, an oral tablet, capsule or liquid form of the prescribed drug so long as the form dispensed or administered has the same strength, dose and dose schedule and is therapeutically equivalent to the drug prescribed."

This surprised me a bit so I dug into your state's law and in that same section they define therapeutically equivalent as:

means drugs that are approved by the United States Food and Drug Administration for interstate distribution and the Food and Drug Administration has determined that the drugs will provide essentially the same efficacy and toxicity when administered to an individual in the same dosage regimen.

To me, "FDA determined ... same efficacy and toxicity" means Orange Book/AB rated.

 

[owlegrad]

I mean it says it has to have the same "strength, dose, and dose schedule..." and talks about not having a unique delivery system.

It means switching between tablets and capsule or liquids, right? Not switching between protonix and prilosec.

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[DrNyvia]

Straight up from the Oregon FAQs:
Q: Does a drug have to be AB rated for generic substitution in Oregon? A: No, it is up to the pharmacist to use their professional judgment. See ORS 689.515 (2)

 

[BidingMyTime]

Straight up from the Oregon FAQs:
Q: Does a drug have to be AB rated for generic substitution in Oregon? A: No, it is up to the pharmacist to use their professional judgment. See ORS 689.515 (2)

I still would NOT take that as meaning therapeutic substitution is legal. I would take that as meaning one could substitute Proair for Proventil, they aren't AB rated, but are considered generics of each other (well technically, they are brands, but you know what I mean.)

 

[Redbones]

I have a question preferably for an educated medical perfesional,I have come across the powerful antioxidant chaga mushroom,online everywhere i look i am finding articles that chaga mushroom has powerful medicinal properties and people are saying along with tons of diferent sites that it is so good for you so on and so on and my search reveals from an online source that was suposidly made up of cancer scientists it is very high in beta carotene which in large doses can cause disease and has a dark side that puts you at risk of disease that can lead to death so why did i find this conflicting information,and the inside of chaga is orange in colour which beta carotene is also so is this safe for drinking tea in small amounts or am i putting myself at risk,all i find is write up after write up about how it destroys cancer and many viruses so to me sounded like something good.I did notice after one cup the next day my eyesight was crystal clear no joke.i just cant seem to find a solid answer on weather or not it is very high in beta carotene or not except for that one article and i cant seem to find it again that kind of gave me a red flag,maybe it is good but needs to be used in small doses can someone give me an idea what to think of it i dont know what to think of it.

 

[Deja]

Let me clarify. The drug does not need to be AB rated to substitute, but therapeutically equivalent (same generic) as determined by the pharmacist's professional opinion. This might be different depending on your state. From my state's Board of Pharmacy:

"2)Except as limited by subsections (3) and (5) of this section, unless the purchaser instructs otherwise, a pharmacist may substitute as follows:

(a)A drug product with the same generic name in the same strength, quantity, dose and dosage form as the prescribed drug which is, in the pharmacists professional opinion, therapeutically equivalent.

(b)When the prescriber is not reasonably available for consultation and the prescribed drug does not utilize a unique delivery system technology, an oral tablet, capsule or liquid form of the prescribed drug so long as the form dispensed or administered has the same strength, dose and dose schedule and is therapeutically equivalent to the drug prescribed."

yeah even with this definition, it seems like you are only allowed to switch between brand/generic OR between tablet and liquid.... not changing from ome to protonix

So yeah I think the doctor would have to indicate that change is allowed on the script instead of just check mark the sub allowed box

 

[CetiAlphaFive]

Was reading this post on the Angry Pharmacist website. It got me thinking. I am not a pharmacist myself, but a 4th year medical student (who worked as a pharmacy technician for several years prior to med school). I was curious as to what SDN pharmacy forums prescribing tips would be to make life easier overall for the retail pharmacist. Perhaps we can get a repository of tips...

Repeat after me:

If I sign a blank C2 prescription and give it to a mid-level to fill out, my license will instantly be banished to the 11th level of super-hell to be tortured by the DEAvil got all eternity.

I mean it says it has to have the same "strength, dose, and dose schedule..." and talks about not having a unique delivery system.

It means switching between tablets and capsule or liquids, right? Not switching between protonix and prilosec.

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Absolutely. It very clearly is talking about changing forms between 1 drug.

 

[WVUPharm2007]

I have a question preferably for an educated medical perfesional,I have come across the powerful antioxidant chaga mushroom,online everywhere i look i am finding articles that chaga mushroom has powerful medicinal properties and people are saying along with tons of diferent sites that it is so good for you so on and so on and my search reveals from an online source that was suposidly made up of cancer scientists it is very high in beta carotene which in large doses can cause disease and has a dark side that puts you at risk of disease that can lead to death so why did i find this conflicting information,and the inside of chaga is orange in colour which beta carotene is also so is this safe for drinking tea in small amounts or am i putting myself at risk,all i find is write up after write up about how it destroys cancer and many viruses so to me sounded like something good.I did notice after one cup the next day my eyesight was crystal clear no joke.i just cant seem to find a solid answer on weather or not it is very high in beta carotene or not except for that one article and i cant seem to find it again that kind of gave me a red flag,maybe it is good but needs to be used in small doses can someone give me an idea what to think of it i dont know what to think of it.

Go ask the kid at GNC.

 

[CynicalIntern]

Go ask the kid at GNC.

This actually sounds like the kind of thing that Unchained could give you some great insight into.

 

[sozme]

If I sign a blank C2 prescription and give it to a mid-level to fill out, my license will instantly be banished to the 11th level of super-hell to be tortured by the DEAvil got all eternity.

In our state, mid-levels couldnt write for C-IIs until a few months ago. It was an incredibly stupid decision by the state legislature.

 

[waiter]

The best thing would be if doctors would answer pharmacist calls instead of sending to voicemail or return calls in timely fashion.

 

[cbrons]

The best thing would be if doctors would answer pharmacist calls instead of sending to voicemail or return calls in timely fashion.

The same could be said of Walgreens phone system, where I'm forced to wait 20 minutes listening to a stupid sales pitch about Flu shots.

 

[CountBy5s]

Can we please add

*** stop sending the same script to 2 or 3 pharmacies bc you didn't ask where the pt wanted the script filled. My crystal ball doesn't tell me where to call to ask for a insurance claim reversal on that OTC Medicaid script.

Thought of a few more...

*** supervising MD name and DEA# on the Middle level scripts for controls.

*** salt forms/complete dosage form of specific drugs hydroxyzine, Depakote, Nifedipine, etc.

 

[PikminOC]

And stop telling them it should be ready by the time you get there

I never tell people this. I tell them to contact the pharmacy to find out if it's ready. I don't know how busy you guys are, but I do know you are generally busy!

 

[PikminOC]

In our state, mid-levels couldnt write for C-IIs until a few months ago. It was an incredibly stupid decision by the state legislature.

Midlevels have massive lobbies due to sheer numbers

 

[PikminOC]

The same could be said of Walgreens phone system, where I'm forced to wait 20 minutes listening to a stupid sales pitch about Flu shots.

Waiting for 20 mins...then tech says you need to talk to pharmacist...20 more mins