Proventil/Proair/Ventolin

[icekitsune]

I was curious to see what other rph would do in regards to changing albuterol inhalers. Rx states roventil (albuterol) 108 (90 base) . Patient insurance only pays for proair. No previous history of fill in the system. Patient doesn't remember which one they took and states that they only use it if her throat swells up but otherwise she doesn't really use it. which would you dispense? I know that the three albuterol are not AB rated so they aren't interchangable.

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[Sparda29]

I was curious to see what other rph would do in regards to changing albuterol inhalers. Rx states roventil (albuterol) 108 (90 base) . Patient insurance only pays for proair. No previous history of fill in the system. Patient doesn't remember which one they took and states that they only use it if her throat swells up but otherwise she doesn't really use it. which would you dispense? I know that the three albuterol are not AB rated so they aren't interchangable.

Just switch it and write md okay change from x to y inhaler, etc. I guarantee you get your ass chewed out if you call.

 

[BenJammin]

My residents will chew your ass out for calling about that. Just change to the albuterol HFA covered and write MD OKAY.

 

[BidingMyTime]

Your doctors need to be trained better to just write "albuterol MDA" and leave the brand name off of it.

 

[MountainPharmD]

Your doctors need to be trained better to just write "albuterol MDA" and leave the brand name off of it.

Winner!

 

[nnguyenc]

Your doctors need to be trained better to just write "albuterol MDA" and leave the brand name off of it.

lol at "albuterol MDA"

 

[MatCauthon]

Every pharmacist I've worked with for the last 6 years substitutes these at will with no subsequent call to the MD. FYI, most states don't require the Orange Book for generic substitution. Read your specific state law for more information. Many pharmacists I work with will regularly change around tablets/capsule dose forms (as long they therapeutically equivalent, not IR to ER changes) without contacting the MD. So if the drug has the same therapeutic efficacy and toxicity we can substitute. Our computer system is even loaded in such a way that proventil/ventolin/proair are interchangeable.

 

[BenJammin]

Your doctors need to be trained better to just write "albuterol MDA" and leave the brand name off of it.

No that's bull****. They automatically default to ProAir and having a retail pharmacy call because "Proventil is the only brand covered" is a waste of time. What doctor is going to say no to that request? Give me a break.

 

[BidingMyTime]

No that's bull****. They automatically default to ProAir and having a retail pharmacy call because "Proventil is the only brand covered" is a waste of time. What doctor is going to say no to that request? Give me a break.

Well, I know that is not true of all systems. From what I've seen, the electronically sent RX's usually just say albuterol, its the handwritten ones that will have a brand name. Most doctors after a call or two, figure it out, and will write generic albuterol.

lol at "albuterol MDA"

hahaha, it was really late when I wrote that, what can I say?

 

[Lnsean]

stop wasting each other time and just switch it...jesus. I had a pharmacist who called the MD office on this...unbelievable. This is the same idiot that blindly filled suboxone 8 films for 10 strips/day.

Script written for Proair' "oh no...I only have ventolin...better bother the MD at 10AM"

Script written for suboxone 8 #120 for 10ds "oh no prob"

 

[trailerpark]

Who calls? Just send a damn fax and be done with it.

 

[Deja]

Who calls? Just send a damn fax and be done with it.

you completely missed the point lol....

okay but is this really a serious question? you are listed as a pre-pharm, maybe thats why.... just change it, I do it and I don't know any other pharmacist who doesn't, even the most "anal" ones lol

 

[Dred Pirate]

No that's bull****. They automatically default to ProAir and having a retail pharmacy call because "Proventil is the only brand covered" is a waste of time. What doctor is going to say no to that request? Give me a break.

1. no one should ever call on things like this - you make our profession a joke
2. Md's should not write a brand unless the really want the brand, write albuterol MDI, prenatal vitamins, etc - lets make each other's jobs easier

 

[zelman]

1. no one should ever call on things like this - you make our profession a joke
2. Md's should not write a brand unless the really want the brand, write albuterol MDI, prenatal vitamins, etc - lets make each other's jobs easier

The laws that say we must call are what makes it a joke.

 

[BenJammin]

1. no one should ever call on things like this - you make our profession a joke
2. Md's should not write a brand unless the really want the brand, write albuterol MDI, prenatal vitamins, etc - lets make each other's jobs easier

Hahahahaha! Get angry some more.

 

[Jibby321]

Proventil is not a MDI so can you technically change it if it says MDI? I see proair changed to ventolin all the time.

 

[SoylentGreen]

I do call. I know it's ridiculous, but that's what our state law calls for. Technically, according to the law and company policy, dispensing a non-AB rated generic is an error. I could see this being enforced if somebody decided to raise hell about it, most likely an employee who's upset that they didn't get their way about something completely unrelated and is trying to get me in trouble (not at all unlikely given the staff I work with), or possibly a customer or doctor who has swallowed some drug rep's koolaid (I did have one nurse practitioner call and complain when I dispensed Proair when Ventolin was written). Our management is crazy enough to enforce this rule if it's brought to their attention. I have seen and heard of trivial crap that everybody does randomly becoming a disciplinary issue.

Doctors may be annoyed by these calls, but I don't suppose they'll be there to pay my bills if I get in trouble over something like this.

 

[Carboxide]

I do call. I know it's ridiculous, but that's what our state law calls for. Technically, according to the law and company policy, dispensing a non-AB rated generic is an error. I could see this being enforced if somebody decided to raise hell about it, most likely an employee who's upset that they didn't get their way about something completely unrelated and is trying to get me in trouble (not at all unlikely given the staff I work with), or possibly a customer or doctor who has swallowed some drug rep's koolaid (I did have one nurse practitioner call and complain when I dispensed Proair when Ventolin was written). Our management is crazy enough to enforce this rule if it's brought to their attention. I have seen and heard of trivial crap that everybody does randomly becoming a disciplinary issue.

Doctors may be annoyed by these calls, but I don't suppose they'll be there to pay my bills if I get in trouble over something like this.

Not all states hold the Orange book as law. Mine doesn't. So no, I don't call.

 

[PharmNerdMatt]

Not all states hold the Orange book as law. Mine doesn't. So no, I don't call.

So, I think it would be reasonable for those that are required to use the Orange book to call, and those that don't can skip the call.

 

[SoylentGreen]

Not all states hold the Orange book as law. Mine doesn't. So no, I don't call.

I would absolutely not call over something like that if my state didn't require it. A lot of people here don't anyway, but I've been burnt over stuff like this before.

 

[pharmalt82]

Even if my state requires it, I don't call.
If the Rx says Proventil but the insurances requires a PA, I just change it to ProAir or Ventolin.
I do annotate the script electronically with the PA message and phone number and lie and annotate that the doctor okd any albuterol mdi that is covered.
If the patient complains, the pharmacist on-duty can see my annotation, alert the patient about the PA and make the patient call the doctor and tell them to get the PA done. 99% of the time, the patient just gets what is covered.
I do believe patients when they say that one pump works better than the others for them. If that is the case, I keep things the same and do what they ask.
I do similar things with liquid antibiotic quantities (ex. 200ml given instead of 150ml because the 75ml bottles are not in stock) and topical drugs.
Why are we wasting our lives on meaningless things like this?
Do you people even value your time?

 

[BidingMyTime]

Do you people even value your time?

Why would we, nobody else values our time.

 

[Ackj]

The prescriber 99.9% of the time wants whatever is best for the patient, and something that the patient will actually take. If they are paying $60-70 out of pocket, they are less likely to take the medication at all. Give them the covered one. If the patient thinks the red one is bad and makes them itchy, they won't take it. So don't give them proair, give them Ventolin or Proventil.

Similarly, the prescribers usually don't care if you give them a 15 vs 30g tube of ointment. If you only have one in stock, don't make a patient go without treatment until you can get the right size. Do what's best for the patient.

 

[BidingMyTime]

The prescriber 99.9% of the time wants whatever is best for the patient, and something that the patient will actually take. If they are paying $60-70 out of pocket, they are less likely to take the medication at all. Give them the covered one. If the patient thinks the red one is bad and makes them itchy, they won't take it. So don't give them proair, give them Ventolin or Proventil.

It's one thing if a doctor has told you "you can always change my prescriptions from Proair to Ventolin", but I would not change a prescription without knowing that individual doctor would OK it. Because doctors don't always do what is in the best interests of their patients. I remember one case with an elderly person who could not afford the cost of brand Coumadin, I called the office, doctor refused to change. I eventually talked to the doctor personally, he said he absolutely would never OK generic Coumadin, I'm like well your patient is absolutely refusing to pay for brand Coumadin, surely generic warfarin would be better than NOTHING??? The doctor felt differently, and patient left without any medication.
I can relate similar stories, where a doctor refused to change a prescription, that obviously should be changed. It's not my job to prescribe, if a doctor refuses to change a prescription in these cases, I tell the patient to consider getting a 2nd opinion.

 

[Wheresmyaricept]

It's one thing if a doctor has told you "you can always change my prescriptions from Proair to Ventolin", but I would not change a prescription without knowing that individual doctor would OK it. Because doctors don't always do what is in the best interests of their patients. I remember one case with an elderly person who could not afford the cost of brand Coumadin, I called the office, doctor refused to change. I eventually talked to the doctor personally, he said he absolutely would never OK generic Coumadin, I'm like well your patient is absolutely refusing to pay for brand Coumadin, surely generic warfarin would be better than NOTHING??? The doctor felt differently, and patient left without any medication.
I can relate similar stories, where a doctor refused to change a prescription, that obviously should be changed. It's not my job to prescribe, if a doctor refuses to change a prescription in these cases, I tell the patient to consider getting a 2nd opinion.

That's just ignorance and arrogance. I had a similar experience with cough medication for a part d patient. Doctor wrote for tussionex, 240 ml and was like over 100 dollars. I called him to see if he would change to prometh with codeine or cheratussin and he said no because he "really wanted her to get this one because it works really good". I was like well she isn't going to get it because she can't afford it...I was floored. Even if it doesn't work as well in your mind, think about your patient...

 

[BidingMyTime]

That's just ignorance and arrogance. I had a similar experience with cough medication for a part d patient. Doctor wrote for tussionex, 240 ml and was like over 100 dollars. I called him to see if he would change to prometh with codeine or cheratussin and he said no because he "really wanted her to get this one because it works really good". I was like well she isn't going to get it because she can't afford it...I was floored. Even if it doesn't work as well in your mind, think about your patient...

I agree, I can't understand why some doctors act this way. They seem completely oblivious to reality and the fact that some of their patients do not have any extra money to pay for prescriptions, and they can't afford to charge more than a few dollars for their prescription on their credit card (if they have a credit card.)

 

[boriqua]

it's amazing how every time i come to this forum, i see a conversation about whether something i do every single day is allowed.
let's flip the script. say you are one of those people who would bother the doctor with something so stupid, what happens if you do not give someone a rescue inhaler and tell them to wait for you to call the doctor and the doctor doesn't respond for days and the patient suffers an asthmatic attack without an inhaler? would "but the state has i have to call.." be a good enough excuse?

 

[zelman]

it's amazing how every time i come to this forum, i see a conversation about whether something i do every single day is allowed.
let's flip the script. say you are one of those people who would bother the doctor with something so stupid, what happens if you do not give someone a rescue inhaler and tell them to wait for you to call the doctor and the doctor doesn't respond for days and the patient suffers an asthmatic attack without an inhaler? would "but the state has i have to call.." be a good enough excuse?

Yes

 

[Lnsean]

it's amazing how every time i come to this forum, i see a conversation about whether something i do every single day is allowed.
let's flip the script. say you are one of those people who would bother the doctor with something so stupid, what happens if you do not give someone a rescue inhaler and tell them to wait for you to call the doctor and the doctor doesn't respond for days and the patient suffers an asthmatic attack without an inhaler? would "but the state has i have to call.." be a good enough excuse?

It's because people have no common sense. Sorry, the computer says I can't so you just have to go without it. All that training I got in pharmacy school? Nah...computer says I can't..so...please...go die at another store...not here...they'll know!

 

[BidingMyTime]

it's amazing how every time i come to this forum, i see a conversation about whether something i do every single day is allowed.
let's flip the script. say you are one of those people who would bother the doctor with something so stupid, what happens if you do not give someone a rescue inhaler and tell them to wait for you to call the doctor and the doctor doesn't respond for days and the patient suffers an asthmatic attack without an inhaler? would "but the state has i have to call.." be a good enough excuse?

People don't get in trouble for following the law, they get in trouble for NOT following the law. The patient is always free to pay cash if their inhaler is not covered by ins. Plus, the patient is always free to go to another pharmacy. If the doctor isn't responding "for days", there is a serious problem with that doctors office, and if the patient is in immediate need, they should go to the emergency room or urgent care. There is ZERO liability for no giving the patient an inhaler for free, because their insurance won't cover it. Now granted, there is pretty close to zero liability if one did change the RX, but if its illegal to change it in ones state, then there is a legal risk, albeit very small--and the defense "I couldn't get ahold of the doctor" would not hold water in a court of law.

 

[FarmD711]

it's amazing how every time i come to this forum, i see a conversation about whether something i do every single day is allowed.
let's flip the script. say you are one of those people who would bother the doctor with something so stupid, what happens if you do not give someone a rescue inhaler and tell them to wait for you to call the doctor and the doctor doesn't respond for days and the patient suffers an asthmatic attack without an inhaler? would "but the state has i have to call.." be a good enough excuse?

Yes, as the patient always has the alternative to pay the cash price. Billing and navigating insurance requirements is a courtesy, not a necessity. If the patient has chosen an insurance that only covers one of the three and the state has a ridiculous requirement that I am not capable of using professional judgment to say that proventil = proair = ventolin than it is up to the patient to decide if it is worth paying the $$$ for the inhaler the Dr wrote for, wait for a call, or go to the ER. Noone should be acutely presenting at my pharmacy on the verge of having an asthma attack for a rescue inhaler. I am not acute care.

 

[Lnsean]

This thread is giving me ebola. Please close it.

 

[boriqua]

People don't get in trouble for following the law, they get in trouble for NOT following the law. The patient is always free to pay cash if their inhaler is not covered by ins. Plus, the patient is always free to go to another pharmacy. If the doctor isn't responding "for days", there is a serious problem with that doctors office, and if the patient is in immediate need, they should go to the emergency room or urgent care. There is ZERO liability for no giving the patient an inhaler for free, because their insurance won't cover it. Now granted, there is pretty close to zero liability if one did change the RX, but if its illegal to change it in ones state, then there is a legal risk, albeit very small--and the defense "I couldn't get ahold of the doctor" would not hold water in a court of law.

Agreed on the zero liability part. as for the doctors responding though, you would be surprised how hard it is to reach a doctor sometimes. We have a giant box of PA's, nonformulary med-switches, inelligible scripts, etc. etc. and we try calling everyday. sometimes the doctor is not there, sometimes the doctor is eating lunch, sometimes the operator is a ***** and transfers you to the wrong area, sometimes it goes to voicemail, sometimes the voicemail is full, sometimes you leave a voicemail and you never hear back from them EVER, sometimes you leave a message with the secretary and she says "ok i'll give it to the doctor", and you call again the next day and the same secretary is like "What message?", sometimes the doctor only works on every other wednesday from 2-3 p.m., sometimes the dingus secretary puts you on hold for 30 minutes so she can finish her doodle jump game on her iphone. etc. We had a doctor try to be cute and send one prescription for ranexa 1000 bid and one for ranexa 500 bid on the same day. had to call to verify cause pt. never got it from us before. that was a month ago. and the doctor sent the same 2 ranexa scripts this month along with the patient's other refills. and believe it or not, this situation does not even crack my top 10 stories about unreachable doctors

 

[Lnsean]

Agreed on the zero liability part. as for the doctors responding though, you would be surprised how hard it is to reach a doctor sometimes. We have a giant box of PA's, nonformulary med-switches, inelligible scripts, etc. etc. and we try calling everyday. sometimes the doctor is not there, sometimes the doctor is eating lunch, sometimes the operator is a ***** and transfers you to the wrong area, sometimes it goes to voicemail, sometimes the voicemail is full, sometimes you leave a voicemail and you never hear back from them EVER, sometimes you leave a message with the secretary and she says "ok i'll give it to the doctor", and you call again the next day and the same secretary is like "What message?", sometimes the doctor only works on every other wednesday from 2-3 p.m., sometimes the dingus secretary puts you on hold for 30 minutes so she can finish her doodle jump game on her iphone. etc. We had a doctor try to be cute and send one prescription for ranexa 1000 bid and one for ranexa 500 bid on the same day. had to call to verify cause pt. never got it from us before. that was a month ago. and the doctor sent the same 2 ranexa scripts this month along with the patient's other refills. and believe it or not, this situation does not even crack my top 10 stories about unreachable doctors

Actually, you guys are all wrong here. There is liability. You are held to the standards of your profession. If you all took pharmacy law, you must have understood this concept. Whether it is written or not, the judge will turn to the jury and ask "did boriqua, in denying the patient an inhaler, acted within the standard of his profession. Would a normal pharmacist in the usual course of his duty acted the same way?" This is where you will get in trouble. Yes, you didn't break any law, but you will be found guilty of negligence.

 

[wagrxm2000]

Actually, you guys are all wrong here. There is liability. You are held to the standards of your profession. If you all took pharmacy law, you must have understood this concept. Whether it is written or not, the judge will turn to the jury and ask "did boriqua, in denying the patient an inhaler, acted within the standard of his profession. Would a normal pharmacist in the usual course of his duty acted the same way?" This is where you will get in trouble. Yes, you didn't break any law, but you will be found guilty of negligence.

Um no, they can pay cash and call the md or go to the office themselves. There's also giving the patient the prescription back and have them fix it if they need it that bad.

 

[PharmNerdMatt]

Actually, you guys are all wrong here. There is liability. You are held to the standards of your profession. If you all took pharmacy law, you must have understood this concept. Whether it is written or not, the judge will turn to the jury and ask "did boriqua, in denying the patient an inhaler, acted within the standard of his profession. Would a normal pharmacist in the usual course of his duty acted the same way?" This is where you will get in trouble. Yes, you didn't break any law, but you will be found guilty of negligence.

Actually, our law professor (a lawyer) taught us that "professional standards" or "standard of care" (the situation you are describing) cannot include an activity that violates the law. Also, you would have to have an expert witness testify that the law is broken on a regular basis, which I doubt you would find someone to do.

I would expect that in these situations (when the doc is difficult to contact) that the physician would maintain some liability.

 

[Lnsean]

Actually, our law professor (a lawyer) taught us that "professional standards" or "standard of care" (the situation you are describing) cannot include an activity that violates the law. Also, you would have to have an expert witness testify that the law is broken on a regular basis, which I doubt you would find someone to do.

I would expect that in these situations (when the doc is difficult to contact) that the physician would maintain some liability.

You're right. Many states allow you to make simple changes, such as dosage forms, or switching Ventolin to Proair first and then informing the doctor later. So, what would be the consequences then? People seem to think that just because you didn't break any laws, you have zero liability, and that is not true at all.

Just saying...please correct me if I am wrong.

 

[Carboxide]

You're right. Many states allow you to make simple changes, such as dosage forms, or switching Ventolin to Proair first and then informing the doctor later. So, what would be the consequences then? People seem to think that just because you didn't break any laws, you have zero liability, and that is not true at all.

Just saying...please correct me if I am wrong.

You are right that not breaking laws does not release you of liability. HOWEVER, if the only alternative available is to break the law, then yes - you are released.

Besides, if the patient was seriously wheezing and you had concerns about their health, you should direct them to the ER.

 

[FarmD711]

You're right. Many states allow you to make simple changes, such as dosage forms, or switching Ventolin to Proair first and then informing the doctor later. So, what would be the consequences then? People seem to think that just because you didn't break any laws, you have zero liability, and that is not true at all.

Just saying...please correct me if I am wrong.

You are wrong.

The patient is not being denied an inhaler. They are just being denied being able to choose which one they would like. If the Rx is written for Ventolin, and insurance does not cover Ventolin, and my state does not allow me to substitute Proair for Ventolin, the patient still has the option to purchase Ventolin at cash price. I am not denying anything.

You sound like the patients that regularly threaten me that they are going to sue me for denying their medication because the insurance doesn't cover Retin-A Micro. My standard response is the same. I'm not denying you anything. The insurance YOU have chosen does not pay for Retin_A Micro. The cost will be $249.99.

 

[Sparda29]

Is this really an argument? Just substitute it and document MD okay without calling.

 

[Lnsean]

Is this really an argument? Just substitute it and document MD okay without calling.

I'm just trolling...apparently this is a huge issue with some people.

 

[Lnsean]

You are wrong.

The patient is not being denied an inhaler. They are just being denied being able to choose which one they would like. If the Rx is written for Ventolin, and insurance does not cover Ventolin, and my state does not allow me to substitute Proair for Ventolin, the patient still has the option to purchase Ventolin at cash price. I am not denying anything.

You sound like the patients that regularly threaten me that they are going to sue me for denying their medication because the insurance doesn't cover Retin-A Micro. My standard response is the same. I'm not denying you anything. The insurance YOU have chosen does not pay for Retin_A Micro. The cost will be $249.99.

Really? You're comparing Ventolin vs Proair sub with Retin-A-Micro? lol

 

[BidingMyTime]

Actually, you guys are all wrong here. There is liability. You are held to the standards of your profession. If you all took pharmacy law, you must have understood this concept. Whether it is written or not, the judge will turn to the jury and ask "did boriqua, in denying the patient an inhaler, acted within the standard of his profession. Would a normal pharmacist in the usual course of his duty acted the same way?" This is where you will get in trouble. Yes, you didn't break any law, but you will be found guilty of negligence.

No, this is not negligence. Nobody is denying the patient their inhaler, they are just expecting the patient to pay for it. Would a normal pharmacist give out free medicines to patients who can't afford this? No, while there are "free" clinics around, I don't know of any area where the standard of practice is to give out a free inhaler to a patient. So, yes refusing to give out an inhaler because the patient wants it for free because its not covered by their insurance is indeed within the standard of practice.

Lets look at the same situation from a different perpective. Let's say the patient's insurance covers Proair, which the patient has a prescription for. But it rejects for being a refill too soon. Patient has a story about how they lost their inhaler, you call the insurance and they tell you they do not pay for lost medications. You tell the patient they will have to pay cash. Patient says you will be responsible when they have an asthma attack because you didn't give them their inhaler for free. Do you really think the pharmacist has any liability in this situation whatsoever? Do you not see the situation is exactly the same as when an inhaler is completely not covered by the insurance?

As a society, we have emergency rooms set up to give medical care to patients regardless of their ability to pay. There is no legal mandate for pharmacists to give out free medicines (or for that matter doctors or nurses or any other medical professional to provide free services in their private offices.)

 

[kvl1027]

This is an example of why we are losing our profession. Why are we so afraid? We are professionals. We are allowed to apply professional judgement. I agree that when we need clarification, we should be able to call for clarification without fear of retribution. But it is this very thing, that makes Prescribers get so pissy with us. Just fill the fricken script! You could defend yourself all day long with the Board on this one.