Change in frequency?

[Curiousone1111]

hey
If you get an rx for same med patient got last month but different frequency, does your system alert you at verificaion? Mine just shows duplicate therapy and the med name but not the sig or quantity so i usually dont pay attention to it until today when i noticed an hiv med pt has been getting bid but the new rx was for qd. I called on that, but other times if its a bp med or whatever i just dispense and counsel. Patient’s bp could be better therefore less pills or worse and getting higher frequency. Do u call on every change of freq or only if it seems important like hiv? Or do u never call because the dr sent it at the end of the day lol?

I have a patient on xanax 1 bid all the time then last month they got TID, i just dispensed after checking Pmp making sure it wasnt early but i didnt refuse to fill just to clarify the sig lol the doctor should pay attention. This month it was back to bid. It is symptom based so i dont think i need to call.


Assuming u guys fill new med and dc the old one within the same drug class without calling md for clarification... If pt comes and doesn’t want the new med in the same class (rosuva vs the atorva last month) and claims it should be like it was last time, obviously dont change the med on the new rx(!!) but would u still refill the old rx atorva (which is probably deactivated by now due to sig change) til u can talk to md?

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[sozetone]

Jeez man , you lost us on paragraph one....you new?

 

[BidingMyTime]

Well, it would depend on the medication and the frequency change....and to a lesser extent if the ordered qty matches the new directions. It's a pharmacist judgement call. If the change seems unlikely or questionable, call the dr. If the changes seems likely or probable, then just make a note to double check with the patient when they come in.

 

[sozetone]

Yeah it's fairly straightforward judgement call. If it's control , then you want to call and be sure everything is kosher, otherwise use your best judgement. Simple retail stuff.

 

[rxkrafted]

you sure do have a lot of questions these days... did you do any internships while you were in school?

 

[Curiousone1111]

you sure do have a lot of questions these days... did you do any internships while you were in school?

I did but I wasn’t the rph so didn’t know what the rph did. My rphs at the chain just dispensed whatever. I never heard them even call md on a drug interaction so it was hard to learn much from them.

 

[Curiousone1111]

If its a control lets say alprazolam 1 mg BID, #60, and supply is all out, I get new rx for TID, i just filled it because its for anxiety and maybe pt has more severe symptoms. My question is what if the patient still has supply on hand from the BID rx, do you calculate how soon they will run out of the BID rx based on the date u receive the TID rx (assuming pt is now taking it tid)?

How about the opposite if they were on tid and now mid therapy we get rx for BID, do u make a patient wait over a month since they picked up the TID since they will run out slower now taking bid? Or just dispense a month after TID was picked up?

If theres a strength change like 5/325 to 7.5/325 i cant ask them to take 1.5 tabs of the 5/325 due to apap component so just dispense the day u get the different strength. But if its a single component med like alprazolam where the new strength is divisible by the old one (new rx 2 mg, old rx 1mg), do u calculate the due date by assuming theyl take 2 of the 1 mg or do u just dispense new strength immediately alwyas?

Yeah it's fairly straightforward judgement call. If it's control , then you want to call and be sure everything is kosher, otherwise use your best judgement. Simple retail stuff.

 

[PA_dud3]

If its a control lets say alprazolam 1 mg BID, #60, and supply is all out, I get new rx for TID, i just filled it because its for anxiety and maybe pt has more severe symptoms. My question is what if the patient still has supply on hand from the BID rx, do you calculate how soon they will run out of the BID rx based on the date u receive the TID rx (assuming pt is now taking it tid)?

How about the opposite if they were on tid and now mid therapy we get rx for BID, do u make a patient wait over a month since they picked up the TID since they will run out slower now taking bid? Or just dispense a month after TID was picked up?

If theres a strength change like 5/325 to 7.5/325 i cant ask them to take 1.5 tabs of the 5/325 due to apap component so just dispense the day u get the different strength. But if its a single component med like alprazolam where the new strength is divisible by the old one (new rx 2 mg, old rx 1mg), do u calculate the due date by assuming theyl take 2 of the 1 mg or do u just dispense new strength immediately alwyas?

If there's a change in dosage or frequency wouldn't you always just fill the most up to date rx and disregard any previous quantity?

 

[owlegrad]

If there's a change in dosage or frequency wouldn't you always just fill the most up to date rx and disregard any previous quantity?

The old pills don’t just disappear because they have a script with a new frequency. That said...”meh”.

 

[PA_dud3]

The old pills don’t just disappear because they have a script with a new frequency. That said...”meh”.

I mean yeah of course they will have some left over, It just seems hard to dose the remainder. You could calculate the remaining days supply left on the old rx using the new directions, I guess, and then not fill it until a couple of days of when the old supply runs out.

 

[owlegrad]

I mean yeah of course they will have some left over, It just seems hard to dose the remainder. You could calculate the remaining days supply left on the old rx using the new directions, I guess, and then not fill it until a couple of days of when the old supply runs out.

Yes, that is the most responsible thing to do for controls. But it always seemed like overkill to me. How many times a year can the frequency increase? It hardly seemed worth tracking to me.

 

[Curiousone1111]

If there's a change in dosage or frequency wouldn't you always just fill the most up to date rx and disregard any previous quantity?

For non controls sure, for controls... i dont really know

 

[Curiousone1111]

Yes, that is the most responsible thing to do for controls. But it always seemed like overkill to me. How many times a year can the frequency increase? It hardly seemed worth tracking to me.

So did u just fill a new frequency once the old supply ran out as taken per old rx or how would u decide if ur not considering the new freq? They couldve started taking it more or less freq as per dr’s new directions and you’d be delaying them if the new rx was more freq and rhey run out

 

[Curiousone1111]

So if the new rx is tid and they get it today, il figure out when the new rx is due based on how many pills are left from bid rx and divide it by 3 to see how long itl last. Theyl run out of the old rx quicker than if they took bid, then fill tid.


But if rx was tid and became bid, are u going to do the same thing and not dispense until >1 month since pick up since the rx will last longer now?... or theres a chance pt cud still be taking tid so just fill the bid once the tid days supply are over?

Change in dosage, if its completely diff dose id dispense right away and tell them to stop the other even tho they will have some on hand. Thats what we do w non controls theyl still have it on hand we cant go n throw it our. But if dosage changes from 1 mg to 2 mg is it fair to expect them to just take 2 tabs and calc new due date based off that instead of dispensing right away?

I mean yeah of course they will have some left over, It just seems hard to dose the remainder. You could calculate the remaining days supply left on the old rx using the new directions, I guess, and then not fill it until a couple of days of when the old supply runs out.

 

[owlegrad]

So did u just fill a new frequency once the old supply ran out as taken per old rx or how would u decide if ur not considering the new freq? They couldve started taking it more or less freq as per dr’s new directions and you’d be delaying them if the new rx was more freq and rhey run out

Lol dude your posts hurt my brain. I would fill it as though it was a totally new script/therapy.

Unless someone finds an old post of mine saying otherwise, in which case I would do that.

 

[Curiousone1111]

Sure but for those rphs who actually count how much is gonna be on hand after a dose increase, they’re going to have issues with PMP. if other rphs are always filling things the minute u get it for a frequency change its going to reflect on PMP as though it was early (esp since ur not even counting how many days the old rx will last after the increase). They couldve gotten 1 mg qd then 1 mg BID a week later and ur just going to fill it. ..
We have to count back a few months

Lol dude your posts hurt my brain. I would fill it as though it was a totally new script/therapy.

Unless someone finds an old post of mine saying otherwise, in which case I would do that.

 

[beautifulrobot]

Sure but for those rphs who actually count how much is gonna be on hand after a dose increase, they’re going to have issues with PMP. if other rphs are always filling things the minute u get it for a frequency change its going to reflect on PMP as though it was early (esp since ur not even counting how many days the old rx will last after the increase). They couldve gotten 1 mg qd then 1 mg BID a week later and ur just going to fill it. ..
We have to count back a few months

Doesnt PMP show DS/sig data to give context to "early" fills (i luckily dont have to deal with PMP in my practice setting, at least for now)? Why do you have to count back a few months? What purpose does this serve? Is this company policy to prevent diversion? If you know the patient and they dont have any other red flags for diversion, do you still have strict company policy around early fills, or do you have the ability to use your judgment for early fills?

What specific concerns do you have with filling a new controlled rx with a different frequency before the patients previous rx day supply is complete?

If you are stuck and not sure what to do, take a step back and think about what would be most helpful to the patient while still fulfulling your responsibility to upholding regulations and company policy. If you dont know or understand the law or company policy, educate yourself. And by understand, i mean that you should be able to clearly explain to a patient why the law or policy exists, especially if it means you are denying or delaying their care. Also, before calling the prescriber, ask yourself if your questions/concerns could reasonably be answered by the patient first. If you think you have an obligation to call the prescriber, make sure you can explain to the prescriber why you had to contact them and you couldnt figure this out on your own.

It seems that you are new at practicing pharmacy, and it's perfectly normal and good to ask questions, but some of the questions you ask demonstrate a lack of critical thinking. I apologize for being a bit harsh, and i may be making some assumptions here, but i am just thinking if i was a patient at your pharmacy or a prescriber sending patients to your pharmacy i would have a hard time working with you. You cant just blame your school for failing to prepare you, you need to take responsibility for your own learning. The reason you get paid the big bucks is because you are supposed to make important judgment calls on your own. If you cant think for yourself and have to call the prescriber on everything you are not 100% familiar with, you are not an effective pharmacist. I dont know what the solution is for your current predicament, though. You could certainly keep asking questions here at SDN, but also maybe read some pharmacy practice journals? Try to overlap with other pharmacists as much as possible and closely observe them? Maybe even during your days off? You owe it to yourself and to your patients to develop the needed critical thinking skills to be an effective pharmacist.

 

[Curiousone1111]

It’s state law that you cant dispense if they have more than a 7 day supply total of any previous fill on hand. Thats why u need to look back and why I started thinking about previous fill and frequency change.

Well, other pharmacists tend to do whatever. Like the nebulizer example insurance only pays for 11 ml a day (four times) but dr wrote for six... rphs keep dispensing and just billing for a greater day supply to make it go thru. Pt knows they will run out quicker and insurance wont pay but then u read stuff about how this is fraud etc. the most i can see happening is maybe a chargeback?

Or with the nicotine gum insurance pays 20 pieces a day rx says 24 and rph is billing as if pt is getting 20 a day. They will run out sooner and if theyre okay with it sure but again the whole insurance aspect i dont know if im doing wrong. I dont think it should be an issue on my license.

Or 2 inhalers written for a child. Idk if school policy still prevents them from carrying inhalers and if one needs to be kept in the nurses office so i always billed 2 if the rx said 2 for a child but obviously itl only go thru if im dispensing for like 30 days even if it actually lasts longer. In that case I can put a note so next rph doesnt rebill before the actual due date but again these are probably chargeback issues because I see it as fairly common in retail.

Doesnt PMP show DS/sig data to give context to "early" fills (i luckily dont have to deal with PMP in my practice setting, at least for now)? Why do you have to count back a few months? What purpose does this serve? Is this company policy to prevent diversion? If you know the patient and they dont have any other red flags for diversion, do you still have strict company policy around early fills, or do you have the ability to use your judgment for early fills?

What specific concerns do you have with filling a new controlled rx with a different frequency before the patients previous rx day supply is complete?

If you are stuck and not sure what to do, take a step back and think about what would be most helpful to the patient while still fulfulling your responsibility to upholding regulations and company policy. If you dont know or understand the law or company policy, educate yourself. And by understand, i mean that you should be able to clearly explain to a patient why the law or policy exists, especially if it means you are denying or delaying their care. Also, before calling the prescriber, ask yourself if your questions/concerns could reasonably be answered by the patient first. If you think you have an obligation to call the prescriber, make sure you can explain to the prescriber why you had to contact them and you couldnt figure this out on your own.

It seems that you are new at practicing pharmacy, and it's perfectly normal and good to ask questions, but some of the questions you ask demonstrate a lack of critical thinking. I apologize for being a bit harsh, and i may be making some assumptions here, but i am just thinking if i was a patient at your pharmacy or a prescriber sending patients to your pharmacy i would have a hard time working with you. You cant just blame your school for failing to prepare you, you need to take responsibility for your own learning. The reason you get paid the big bucks is because you are supposed to make important judgment calls on your own. If you cant think for yourself and have to call the prescriber on everything you are not 100% familiar with, you are not an effective pharmacist. I dont know what the solution is for your current predicament, though. You could certainly keep asking questions here at SDN, but also maybe read some pharmacy practice journals? Try to overlap with other pharmacists as much as possible and closely observe them? Maybe even during your days off? You owe it to yourself and to your patients to develop the needed critical thinking skills to be an effective pharmacist.

 

[beautifulrobot]

It’s state law that you cant dispense if they have more than a 7 day supply total of any previous fill on hand. Thats why u need to look back and why I started thinking about previous fill and frequency change.

Is this for opiates only, or for all controlled substances? Does the law specify any exemptions? Does the law really many any previous fill, or is there some limit on how far back you are supposed to check? I know patients who have been on a controlled substance continuously for over a decade.

Well, other pharmacists tend to do whatever. Like the nebulizer example insurance only pays for 11 ml a day (four times) but dr wrote for six... rphs keep dispensing and just billing for a greater day supply to make it go thru. Pt knows they will run out quicker and insurance wont pay but then u read stuff about how this is fraud etc. the most i can see happening is maybe a chargeback?

I would bill whatever i can through insurance and make the patient pay out of pocket for the rest. If the patient or prescriber have an issue with that they can contact insurance to get a prior auth for a higher daily dose.

Or with the nicotine gum insurance pays 20 pieces a day rx says 24 and rph is billing as if pt is getting 20 a day. They will run out sooner and if theyre okay with it sure but again the whole insurance aspect i dont know if im doing wrong. I dont think it should be an issue on my license.

Same deal, bill what you can to insurance and have pt pay out of pocket for rest, explain that it is an insurance issue, and instruct them to contact their insurance to negotiate more coverage. You can go above and beyond by contacting the insurance on the patient's behalf and see if you can get an override.

Idk if school policy still prevents them from carrying inhalers and if one needs to be kept in the nurses office...

Ask the caregiver if you dont know and you need to know.

...so i always billed 2 if the rx said 2 for a child but obviously itl only go thru if im dispensing for like 30 days even if it actually lasts longer. In that case I can put a note so next rph doesnt rebill before the actual due date but again these are probably chargeback issues because I see it as fairly common in retail.

Calculate day supply based on max dosing prescribed. If it is less than 30 days for both inhalers and insurance pays for it, then great. If not, and the child needs two inhalers to be stored in two different places, the correct way is to create two different scripts for each inhaler. If insurance will pay for both, great, if not, pt pays out of pocket for extra inhaler and/or inquire with insurance if they will give an override for an extra school inhaler.

A lot of these insurance issues are things a well-trained tech should be able to handle independently.

ETA:
If insurance only pays for 20 pieces of nicotine gum per day, and the patient needs more, there are a few things you can do before just going ahead and filling the prescription as-is. Is their a higher strength nicotine gum the patient can switch to? Can the gum be combined with the patch to reduce the amount of nicotine gum pieces needed? Is the patient using the nicotine gum correctly (e.g., chewing and parking the gum several times per piece of gum)? I would think of all of these things before calling the prescriber and asking them to change the prescription because the insurance won't pay for more than 20 pieces of gum per day. If I am asking the prescriber to change a prescription because of insurance issues, I will also offer them a specific suggestion for an alternative treatment plan that insurance will cover.

Similar thoughts about the high dose nebulizer. I don't remember the specifics you posted about this in the other thread, but why do they need so many doses per day? Insurance companies, although motivated by profit, do have some rationale based in evidence for their formulary restrictions. Is there another drug that is longer acting that insurance will cover that the prescriber could consider prescribing instead? If the prescriber insists on using off-label dosing that insurance wont pay for instead of trying an alternate treatment plan that insurance will pay for, it is still fine to fill and have the patient pay out of pocket for whatever insurance wont cover (as long as the risks don't clearly outweigh the benefits and put the patient at unreasonable risk for harm).

The way I see it there are two basic choices in these situations that are both reasonable: 1) fill the prescription as-is, bill insurance for the amount they will cover, and tell the patient they will have to pay out of pocket for the rest, or 2) call the prescriber and suggest a specific treatment plan that insurance will cover, if applicable. Usually talking to the patient to get a better idea of what is going on and their willingness to pay out of pocket for the prescribed treatment can help stir which decision to go with.

 

[Curiousone1111]

It is for all controls, and honestly I don’t think people really follow the rule to that extent because as u said, there are ppl on them chronically lol who can sit and count back everything?

Your reply was very helpful. I always call and try to switch to the frequency that is covered because as u said there is a reasoning behind it, but if MD insists, i’ll explain to the parent the dose is high but doc wants it. As for insurance, I guess at the end of the day it is a chargeback issue. I was more concerned with “fraud” as someone mentioned in one of the other posts, and it affecting my license. Thank you!

Is this for opiates only, or for all controlled substances? Does the law specify any exemptions? Does the law really many any previous fill, or is there some limit on how far back you are supposed to check? I know patients who have been on a controlled substance continuously for over a decade.



I would bill whatever i can through insurance and make the patient pay out of pocket for the rest. If the patient or prescriber have an issue with that they can contact insurance to get a prior auth for a higher daily dose.




Same deal, bill what you can to insurance and have pt pay out of pocket for rest, explain that it is an insurance issue, and instruct them to contact their insurance to negotiate more coverage. You can go above and beyond by contacting the insurance on the patient's behalf and see if you can get an override.



Ask the caregiver if you dont know and you need to know.



Calculate day supply based on max dosing prescribed. If it is less than 30 days for both inhalers and insurance pays for it, then great. If not, and the child needs two inhalers to be stored in two different places, the correct way is to create two different scripts for each inhaler. If insurance will pay for both, great, if not, pt pays out of pocket for extra inhaler and/or inquire with insurance if they will give an override for an extra school inhaler.

A lot of these insurance issues are things a well-trained tech should be able to handle independently.

ETA:
If insurance only pays for 20 pieces of nicotine gum per day, and the patient needs more, there are a few things you can do before just going ahead and filling the prescription as-is. Is their a higher strength nicotine gum the patient can switch to? Can the gum be combined with the patch to reduce the amount of nicotine gum pieces needed? Is the patient using the nicotine gum correctly (e.g., chewing and parking the gum several times per piece of gum)? I would think of all of these things before calling the prescriber and asking them to change the prescription because the insurance won't pay for more than 20 pieces of gum per day. If I am asking the prescriber to change a prescription because of insurance issues, I will also offer them a specific suggestion for an alternative treatment plan that insurance will cover.

Similar thoughts about the high dose nebulizer. I don't remember the specifics you posted about this in the other thread, but why do they need so many doses per day? Insurance companies, although motivated by profit, do have some rationale based in evidence for their formulary restrictions. Is there another drug that is longer acting that insurance will cover that the prescriber could consider prescribing instead? If the prescriber insists on using off-label dosing that insurance wont pay for instead of trying an alternate treatment plan that insurance will pay for, it is still fine to fill and have the patient pay out of pocket for whatever insurance wont cover (as long as the risks don't clearly outweigh the benefits and put the patient at unreasonable risk for harm).

The way I see it there are two basic choices in these situations that are both reasonable: 1) fill the prescription as-is, bill insurance for the amount they will cover, and tell the patient they will have to pay out of pocket for the rest, or 2) call the prescriber and suggest a specific treatment plan that insurance will cover, if applicable. Usually talking to the patient to get a better idea of what is going on and their willingness to pay out of pocket for the prescribed treatment can help stir which decision to go with.

 

[BidingMyTime]

As for insurance, I guess at the end of the day it is a chargeback issue. I was more concerned with “fraud” as someone mentioned in one of the other posts, and it affecting my license. Thank you!

If you are routinely shortening days supply to get something to go through insurance (ie running 2 inhalers as 25 days supply when they are actually 50 days supply), then yes, you could get in trouble for insurance fraud. Especially if you are doing this for Medicaid/Medicare patients. (If it's just an occasional happening, then it's more likely to be written off as an error.)

There is no issue with lengthening the days supply of a medicine. IE there is no issue with insurance companies if you run the 2 inhalers as a 90 day supply, instead of the 50 day supply they actually are. (Your co-workers may hate you when they get a RTS rejection when the patient tries to refill at Day 50, but you have done nothing unethical or illegal.)

Really, people have explained all of this to you already in this thread. Either you believe us or you don't. Do you talk to any of your co-workers? What do they say? Do you think your co-workers are lying to you? If you can't trust your co-workers not to lie to you, then you have bigger issues than worrying about billing days supply.