Product Substitutions and Other RX Changes Without MD Input

[clarkbar]

I understand you can substitute ProAir 8.5gm for Ventolin 90mcg/actuation 18gm if the MD specified 8.5gm, the active ingredient being bioequivalent. How far can you take this sort of liberty before insurance or the MD gets upset? What are the limits for the pharmacist to purview these things? Thanks!

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[cj98]

I was told to always call on those to get permission to switch. If it's an emergency or if the doctors are closed for the weekend, I just use my own descretion, document my reasoning and change it on my own

 

[Sine Cura]

I think the BX rating for all of the HFAs (they were all approved via NDA) was meant to make clear that you could not automatically substitute HFA for CFC or one HFA for another.

Some states do not recognize the Orange Book so substitution without prescriber authorization is not required (of course 99% of albuterol scripts are billed to third party so documentation is de facto required anyway).

One way you could get in "trouble" is if the patient really expected a particular brand but got another because you substituted without informing them first. Some hypochondriacs don't like ProAir. Some people actually have an intolerance to the excipients in Ventolin vs ProAir. So some care "should" be taken to avoid these problems.

 

[zelman]

I understand you can substitute ProAir 8.5gm for Ventolin 90mcg/actuation 18gm if the MD specified 8.5gm, the active ingredient being bioequivalent. How far can you take this sort of liberty before insurance or the MD gets upset? What are the limits for the pharmacist to purview these things? Thanks!

Insurance will get upset for this. Most MD's will not. None of it is legally permitted, but often corners are cut do deal with adverse work situations.

 

[clarkbar]

Can you elaborate on what is 'routine,' what are the most common trouble shootings? Particularly with vets and physician assistants, there are many gaffs like this.

 

[CynicalIntern]

If you're calling the doctors office to change albuterol inhalers between manufacturers, you're the pharmacist that all the doctors offices hate.

 

[ancienbon]

If you're calling the doctors office to change albuterol inhalers between manufacturers, you're the pharmacist that all the doctors offices hate.

I agree.

 

[trailerpark]

If your a doctors office that writes for a specific brand instead of Albuterol HFA (Proventil/ProAir/Ventolin) you're the doctors office all the pharmacies hate.


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[Rockinacoustic]

If your a doctors office that writes for a specific brand instead of Albuterol HFA (Proventil/ProAir/Ventolin) you're the doctors office all the pharmacies hate.

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Just don't be the pharmacist who pages the prescriber at 9pm Friday night to get a verbal okay to change from Ventolin to ProAir...

 

[confettiflyer]

I usually wait 'til I have a working relationship w/ the doc before changing orders/reading their mind. I have one doc who updates cisplatin orders but doesn't carry over changes to the pre/post hydration schedule, so I'll routinely strike out mannitol/K/etc... based on previous orders, or his particular practice. Saves everyone time.

With my inpt docs, my changes fall into basic categories:

1) Hard stop, page the doc, leave in queue until clarified (major stuff, major confusion, suboptimal abx regimen that I need to discuss, new doc I haven't worked with, etc...)
2) Change it/do it, page the doc an FYI (ie "hey you continued pt's home flexeril dose, just found out they only take it at night PRN, changed it for you, call me if you had something else in mind, ie "hey talked to RD re: TPN, made recommended changes, will order for you, let me know if you wanted to discuss").
3) Change it, route it back to the doc for a cosignature (more of a CYA)
4) Change it, no physician contact (timing issues, pt took the dose PTA & doc defaulted it to a now dose so change to next day, adding more specific PRN instructions, rates, etc...)

 

[radio frequency]

I especially dislike the amoxicillin 500 mg as tabs and cephalexin as tabs prescriptions. For some offices where I know I'll never reach anybody and they only care that the patient gets the right medication at a reasonable price, I switch to caps without calling. For the big name institution nearby where they could get me in trouble (and tend to be nitpicky), I call and send a message and if they don't get back to me in time, I switch for the patient and document on the prescription if they are in the store. For insurance issues with albuterols I do the same (this happens much less frequently).

 

[mentos]

If you switch Proair to Ventolin without documenting MD approval then insurance won't pay for it during an audit.

 

[Dred Pirate]

I usually wait 'til I have a working relationship w/ the doc before changing orders/reading their mind. I have one doc who updates cisplatin orders but doesn't carry over changes to the pre/post hydration schedule, so I'll routinely strike out mannitol/K/etc... based on previous orders, or his particular practice. Saves everyone time.

With my inpt docs, my changes fall into basic categories:

1) Hard stop, page the doc, leave in queue until clarified (major stuff, major confusion, suboptimal abx regimen that I need to discuss, new doc I haven't worked with, etc...)
2) Change it/do it, page the doc an FYI (ie "hey you continued pt's home flexeril dose, just found out they only take it at night PRN, changed it for you, call me if you had something else in mind, ie "hey talked to RD re: TPN, made recommended changes, will order for you, let me know if you wanted to discuss").
3) Change it, route it back to the doc for a cosignature (more of a CYA)
4) Change it, no physician contact (timing issues, pt took the dose PTA & doc defaulted it to a now dose so change to next day, adding more specific PRN instructions, rates, etc...)

agree with you on this - although the OP is talking the retail world - in these situation the retail world and hospital world are two completely different animals. - although for 2 - I usually still route that back for a cosignature - it takes them 5 seconds to sign and lets them know I am looking out for them

 

[maria1oh]

birth controls are another one. If the doctor writes sprintec can I switch it to another birth control brand if ingredients are the same. The ipledge drugs are another brand/generic issue. As long as doctor doesn't write daw or patient request daw then it should be fine to switch.

 

[Deja]

If you switch Proair to Ventolin without documenting MD approval then insurance won't pay for it during an audit.

i havent worked in a pharmacy where they don't change it automatically... do you guys seriously call on these? jesus

 

[maria1oh]

MTM Outcomes has TIP for switching proair to ventolin and it results in $10 reimbursement. It requires a call to MD.

 

[WVUPharm2007]

MTM Outcomes has TIP for switching proair to ventolin and it results in $10 reimbursement. It requires a call to MD.

God damn, free money.

 

[txpharmguy]

If kiddo was prescribed pills and mom wants a liquid form, document on hardcopy "mom wants liquid" and convert to appropriate amount of liquid. (One caveat, be careful with Augmentin. The amount of clauvulanate in the pills is different in the amount of clauvulanate in liquid form when converting amoxicillin equivalents. This would require call to prescriber.)

 

[waiter]

tizanidine caps to tabs have to call every single time unfortunately

 

[CynicalIntern]

i havent worked in a pharmacy where they don't change it automatically... do you guys seriously call on these? jesus

My go to answer: "Every office in the world has a receptionist named Amy. Amy is very helpful. Amy always is the one that I talk to who says "sure, it's okay to swap your Proair to Ventolin, and your capsules to tablets, and that's how I document that on the script.

 

[zelman]

My go to answer: "Every office in the world has a receptionist named Amy. Amy is very helpful. Amy always is the one that I talk to who says "sure, it's okay to swap your Proair to Ventolin, and your capsules to tablets, and that's how I document that on the script.

I'd go "Mary" but maybe it's regional.

 

[owlegrad]

Mine was named Jenn.

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[mentos]

i havent worked in a pharmacy where they don't change it automatically... do you guys seriously call on these? jesus

We fax, it's faster.

 

[Rukn]

I never call on that stuff

just change it and put md ok and move in with your life

 

[wagrxm2000]

Surprised no one said this. All you do is call your local offices and get verbal verification one time for all common switches (inhaler, capsules, certain form medicaid wants etc). Either that or like above just put verified with md and if they say they didn't just say they never document changes.

 

[Apotheker2015]

i havent worked in a pharmacy where they don't change it automatically... do you guys seriously call on these? jesus

Exactly, whatever insurance pays for IS what you dispense. These days you don't even add a note to the script if that's the case. Does anybody want to talk about pharmacists wasting time on calling a prescriber because you have only have doxycycline hyclate in stock and the script calls for doxycycline monohydrate? A preceptor of mine was about to lose it because of all the phone calls they were making to get the switch approved and it was always approved without hesitation. So that became a mini-project of mine. There is no significant difference in any pharmacokinetic parameters. The only reason to avoid hyclate and insist on monohydrate is the fact, that hyclate can increase the risk of bleeding especially in patients that are high risk. Thus, if your patient is on Warfarin, Eliquis, Xarelto, etc, then you avoid hyclate.n Simple. Other than that, don't waste anyone's time and switch it. Or if the RPH is stubborn and still wants to call, just have them ask the first time "doc, is it ok with you to switch this in the future unless there is an imminent risk of X,Y,Z?" Doc will say "Awesome, yes, for sure"

 

[radio frequency]

Exactly, whatever insurance pays for IS what you dispense. These days you don't even add a note to the script if that's the case. Does anybody want to talk about pharmacists wasting time on calling a prescriber because you have only have doxycycline hyclate in stock and the script calls for doxycycline monohydrate? A preceptor of mine was about to lose it because of all the phone calls they were making to get the switch approved and it was always approved without hesitation. So that became a mini-project of mine. There is no significant difference in any pharmacokinetic parameters. The only reason to avoid hyclate and insist on monohydrate is the fact, that hyclate can increase the risk of bleeding especially in patients that are high risk. Thus, if your patient is on Warfarin, Eliquis, Xarelto, etc, then you avoid hyclate.n Simple. Other than that, don't waste anyone's time and switch it. Or if the RPH is stubborn and still wants to call, just have them ask the first time "doc, is it ok with you to switch this in the future unless there is an imminent risk of X,Y,Z?" Doc will say "Awesome, yes, for sure"

Yeah, but if they write hyclate and you switch to monohydrate without an approval note on the Rx, aren't you subject to insurance chargebacks in case of audits? Luckily my local docs have mostly figured this out and just write "doxycycline" with no specifications re: tabs, caps, monohydrate or hyclate, or they write "may use any form available" on the Rx.

 

[boriqua]

me: hi i'm calling on behalf of a patient that you prescribed omeprazole for. it's not covered by their insurance, can i substitute for pepcid?
Doctor: I'm sorry, are you the pharmacist? or am i the pharmacist?
me: umm...me?
Doctor: ok so give the patient whatever the hell you think is good and is covered and stop calling here!
*click*

 

[txpharmguy]

Most of the time if something isn't covered, I figure out what's covered and fax for that product. 99/100 it's changed. Saves medical staff from time on phone and gets pt medication faster. For instance, if Advair isn't covered, I try Dulera, Symbicort, or Breo Ellipta

 

[confettiflyer]

Before our CPOE system automatically imported formulary information and stuff, I would occasionally be deputized by a physician to cut down on calls:

doc: Hey, I'm discharging this patient on doxycycline...I have no idea what form is covered, do you know?
me: I don't know either...here, put "dispense any doxycycline form covered by insurance" in the comment
doc: okay, I can do that. sometimes they still call though.
me: Here I know, put my name & the pharmacy phone number. I'll give them a verbal order from you if they're being picky.

Sometimes when I'm floating through ED I'd field the "call to change" calls, I pretty much have free reign to change therapy (within reason...which is why we went to school in the first place, right?)

And as an aside: "OK per MD/DO" to me doesn't necessarily imply an actual physical phone call happened.

 

[Dred Pirate]

me: hi i'm calling on behalf of a patient that you prescribed omeprazole for. it's not covered by their insurance, can i substitute for pepcid?
Doctor: I'm sorry, are you the pharmacist? or am i the pharmacist?
me: umm...me?
Doctor: ok so give the patient whatever the hell you think is good and is covered and stop calling here!
*click*

ah? I wouldn't change drug classes without calling the doc.

 

[confettiflyer]

ah? I wouldn't change drug classes without calling the doc.

I wouldn't either, who knows what they're treating or what they've tried and failed before.

Even esomeprazole to omeprazole....maybe they failed omeprazole and hence doc switched to Nexium and your next step is to really file a prior auth.

But again we went to school to discern these things, but I'd make a mental note that the doc in the example just issued a standing order to give whatever PPI/H2RA is covered.

 

[radio frequency]

I wouldn't either, who knows what they're treating or what they've tried and failed before.

Even esomeprazole to omeprazole....maybe they failed omeprazole and hence doc switched to Nexium and your next step is to really file a prior auth.

But again we went to school to discern these things, but I'd make a mental note that the doc in the example just issued a standing order to give whatever PPI/H2RA is covered.

Agreed with all above, but I've worked with pharmacists I wouldn't trust to make even these basic substitutions as I know their documentation will fall completely short and they may not actually discuss with the patient adequately.

 

[Apotheker2015]

Yeah, but if they write hyclate and you switch to monohydrate without an approval note on the Rx, aren't you subject to insurance chargebacks in case of audits? Luckily my local docs have mostly figured this out and just write "doxycycline" with no specifications re: tabs, caps, monohydrate or hyclate, or they write "may use any form available" on the Rx.

No, that's when you use your clinical judgement. It's the reason you paid so much $$$ for a PharmD. Read my statement again. Monohydrate vs. hyclate: They're in essence the same thing. If there is no DAW on the script I will dispense whichever doxycycline is covered. It's never been a problem. No pharmacist of mine is to waste precious time on that phone call or to get authorization to switch a script written for capsules caps to tablets. Both instances are a misuse of resources.

 

[FarmD711]

No, that's when you use your clinical judgement. It's the reason you paid so much $$$ for a PharmD. Read my statement again. Monohydrate vs. hyclate: They're in essence the same thing. If there is no DAW on the script I will dispense whichever doxycycline is covered. It's never been a problem. No pharmacist of mine is to waste precious time on that phone call or to get authorization to switch a script written for capsules caps to tablets. Both instances are a misuse of resources.

Then the orange book/state law/auditors should reflect that we are allowed to do this. Are we likely to get in trouble for this? No. Are we permitted to? Also no. Not by third party contracts, not by the law, not by our employers, not by our liability insurance, not by our boards. A debate over whether we should be able to make these switches is great. Calling pharmacists who protect themselves and their stores profits "wasting time" is misguided.


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[confettiflyer]

No, that's when you use your clinical judgement. It's the reason you paid so much $$$ for a PharmD. Read my statement again. Monohydrate vs. hyclate: They're in essence the same thing. If there is no DAW on the script I will dispense whichever doxycycline is covered. It's never been a problem. No pharmacist of mine is to waste precious time on that phone call or to get authorization to switch a script written for capsules caps to tablets. Both instances are a misuse of resources.

While I agree with you, the issue isn't clinical judgment here, it's running a business and dealing with bitches for insurance companies that will find any reason to deny a pharmacist money.

Just document and move on, I say.

 

[Apotheker2015]

While I agree with you, the issue isn't clinical judgment here, it's running a business and dealing with bitches for insurance companies that will find any reason to deny a pharmacist money.

Just document and move on, I say.

Definitely. I do that. "Hyclate not covered by insurance". Done.

 

[FarmD711]

Definitely. I do that. "Hyclate not covered by insurance". Done.

This is not acceptable documentation for third party auditors


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[confettiflyer]

This is not acceptable documentation for third party auditors

Can we just call them insurance bitches, please? Because that's what they are.

 

[CynicalIntern]

If your insurance auditors are picking random doxycycline prescriptions to analyze, I want to trade auditors with you. Mine have never at any point looked at something that costs less than 800 for the fill.

 

[zelman]

If your insurance auditors are picking random doxycycline prescriptions to analyze, I want to trade auditors with you. Mine have never at any point looked at something that costs less than 800 for the fill.

...so Doryx?

 

[FarmD711]

If your insurance auditors are picking random doxycycline prescriptions to analyze, I want to trade auditors with you. Mine have never at any point looked at something that costs less than 800 for the fill.

They also look at the expensive stuff in my audits.

But if they find an undocumented doxy switch for example, they don't only get the money from that claim back. It is extrapolated among all claims including the ones they don't check. They're always finding ways to claw back reimbursement. Make sure you write that override code on the back of your vacation supply hard copy haha.


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[confettiflyer]

It's all a big game, like conjuring up receipts for a tax audit, all the same. Pencil pusher needs something to do, something to find so they can get paid at the end of the day. I don't fault them for that, someone has to do the stupid work.

 

[Apotheker2015]

Time of death: 12:37 AM 6/23/16