Control early refill?

Discussion in 'Pharmacy' started by Momus, Apr 24, 2012.

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  1. Momus

    Momus 7+ Year Member

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    Would you fill controlled substance rx 30 days supply, 8 days early if it goes through insurance? I am not comfortable if a patient keeps filling CS early where they can stock pile meds...

    I had customers pretty much scream and yelled at me because I would not fill if it is way too early, I told them 2-3 days early is ok...

    California
    Say Vicodin #180 tabs/30 days, 8 days early (48 tab extra/month)
     
    Last edited: Apr 24, 2012
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  3. rxlea

    rxlea Almost a unicorn Moderator Emeritus 7+ Year Member

    If it goes through insurance, why not. It's hard to be police. Also, not all may be drug seekers. Maybe they aren't getting adequate pain control. I'd ask them more questions about their pain. Alternatively, you could contact the physician if you think it's a huge problem. Maybe the physician isn't aware. I think it's important for the physician and pharmacist to communicate with these situations.

    I'm only a student so take it however.
     
  4. amox

    amox 2+ Year Member

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    I generally ask the patient why they need it early. If they say they are out, you know they are not taking as prescribed and you contact physician. If the patient is not out and has enough to last, explain that you feel comfortable filling it with 3 days left. You can also explain that this limits the amount of substance available on the street whether they are abusing or not and this is your policy. This is what I've seen about 50 techs/pharmacists do and there are few complaints. Usually the people that argue are those who abuse.

    I also agree that we are not the police, but we do have a duty to ensure proper medication use.
     
  5. Momus

    Momus 7+ Year Member

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    Your license is on the line if he/she dies because you fill it early all the time. You can easily see someone who gets Norco 10 #240 tabs/30 days will have extra 56 tablets @ 7 days early. Do that 4 times, you just dispense 200 tablets more than he is prescribed for. What do you say to the board/judge when he ODs? "Well, it goes through ins..."
     
  6. rxlea

    rxlea Almost a unicorn Moderator Emeritus 7+ Year Member

    I see what you're saying and it's true. I think I would definitely ask why they need it so early and communicate your concerns with the physician.
     
  7. pezdispenser

    pezdispenser 10+ Year Member

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    I'm starting to see prescribers write on the Rx "must last 30 days". So take your Vicodin #180/30 days example, and even if the sig is 1-2 q4-6h prn, I will have no hesitation to tell the patient they're SOL if they try to refill it more than 3 days early.

    I guess these prescribers are doing this because of the DEA crackdowns, but I also feel that there is a bit of consensus that prescribers do not like early refills either, so I am comfortable to practice to the same strict standard for all scripts, even if they don't write "must last 30 days".
     
  8. schamj01

    schamj01 2+ Year Member

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    I thought this was an issue that was more tightly policed. Where I work, we can only fill controls 2 days early. No exceptions unless the prescriber specifically tells the pharmacist it is ok.
     
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  9. Dr Wario

    Dr Wario Hey you! Want to try this pill? 5+ Year Member

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    I would tell them that this is not ****ing kindergarten and the patient choose to take the medication inconsistent with the manner in which it was prescribed. If doctors really wanted to curb this, they can simply tell the patient that more refills will not be given for x amount of time (the script is written for 1 month plus 3 refills the patient only gets more refills after 3.6 months).

    The only, and I mean ONLY, reason I concern myself with early refills of controlled substances at all is because the DEA forces me to by holding me responsible for what the patient decides to do to themselves.
     
  10. Ackj

    Ackj 7+ Year Member

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    NY has a law against it. May not dispense if they possess a 7 day supply, for the lifetime of therapy. So if they get it 5 days early this month, and 2 days early next month, they cannot have it early ever again. Of course in a non-abuser, those "early" days go away since they'll come in late a few days too.
     
  11. BrightLight

    BrightLight 2+ Year Member

    Depends on their attitude when asking for early refills. If they act courteous and behaved, I would allow 3-4 days early (so would most of the pharmacy managers I have worked with). But if they act like filthy parasites and try to harass me and my staff just because they want to get high, no refills until the very last day the med is due.
     
  12. amy786

    amy786 7+ Year Member

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    In response to ackj:
    I recently looked this up, for NYS it is the lifetime of the prescription but I think it may mean since the previous prescription. Or maybe I'm misinterpreting it?

    Section 80.69 - Schedule III, IV and V substances
    (c) No additional prescriptions for a controlled substance may be issued by a practitioner to an ultimate user within 30 days of the date of any prescription previously issued unless and until the ultimate user has exhausted all but a seven days' supply of that controlled substance provided by any previously issued prescription.
     
  13. Ackj

    Ackj 7+ Year Member

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    A commonly debated point, and it is certainly worded ambiguously. The part where it says "supply of that controlled substance" is what allows the rule to carry over for lifetime of therapy. If you're getting oxycodone every month, and you should have 7 days worth, you can't get a new rx for oxycodone. Changes in the dosing or frequency obviously affect it. Of course, I suppose you could pop them all and say "I have a zero day's supply!" but that's not really a sound interpretation.

    With the interpretation I've experienced, the problem then becomes: how far back do I have to look? They got it 2 days early 3 months ago, and 1 day early back in october.... Then if the patient goes to another pharmacy, you can no longer keep track of the 7 days.
     
  14. StevePerry

    StevePerry Banned 2+ Year Member

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    Honestly, with the current climate I would either pursue a policy like this and enforce it across the board without exception, or keep it at exactly 30 days. My guess is that insurances will start to not pay claims early for controls in the near future. Anyone work for a PBM and have any insight on this?

    Speaking of which, where is the mild-mannered Mountain by the way?
     
  15. Ackj

    Ackj 7+ Year Member

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    But what if that prescriber runs a pill mill and they say it is okay all the time?
     
  16. NorthwestRph

    NorthwestRph

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    We dispense a lot of controlleds at my pharmacy. Refills are fine only if 2 days before due date. The only exceptions I made was if the patient was polite and managed to convince me they're going on a trip. If they did get it early then I would put a note in their record and I would tell them, I put a note in your record, so everyone will know you got it early for this reason. I've had a lot of patients scream and throw temper tantrums but I turn a deaf ear.

    My problem though is that my partner doesn't have the same policy..if it goes through insurance then he'll give it to them. I've had patients yell that I'm being unfair because the other pharmacist would let them have it. I've had doctors call me upset that their patient has already gone through all their refills so fast, even though the doctor didn't write "must last 30 days". I always tell the doctor that some pharmacists are not so strict.
     
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  17. Momus

    Momus 7+ Year Member

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    I have this problem also. Someone deferred cs rx 8 days early that went through insurance and told pt that it was ok to fill. Came my shift at 12 AM, I refused to fill the rx and pt turned banana on me, I couldn't really call the doc at 12 AM so I ended up filling it anyway after getting creamed by customer. Of course, I told the customer, I'll not fill it again next time... This happens multiple times; enough for me to play the sneaky bastard and fax pt cs refill history to MD to let them know that pt has been refilling CS early... Most of the time, MD will let me know not to fill it early again.
     
    Last edited: Apr 26, 2012
  18. Bernardo123

    Bernardo123

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    I'd like to see a list of pharmacists that have lost their licence for filling a valid prescription. What would make me happier, is to see a list of pharmacists that have interfered with filling a valid prescription, due to their own assumptions, and the patient committed suicide due to not having their required medication. I think if you want to be a doctor, then be a doctor. You are not doctors.. Don't act like it.
    By the way, I have many professional licenses.. if I felt the need to be the police, I would have been a cop. People do things they aren't supposed to do all the time, like taking too many of their pills, or interfering with someone else's medication, just because they feel the need to gain control over someone or something. Stop being ridiculous. Preventing someone from filling a valid script a week early IS NOT going to put your license on the line. You are being as ignorant as the addicts of which you speak.
     
  19. stoichiometrist

    stoichiometrist 5+ Year Member

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    Welcome to SDN. Since you seemingly created an account just to post this, please give us a list of professional licenses you mention you have.
     
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  20. Digsbe

    Digsbe 5+ Year Member

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    Nice necro.

    PhamD's are doctors. If a chiro is a doctor, a dentist is a doctor, a podiatrist is a doctor, and a naturopath is "doctor" then so are doctorate degree holding professionals who put in 4 years of professional schooling just like their counterparts (which in the case of chiro's we do more). Pharmacists have been held liable and have lost lawsuits when patients have sued regarding early refills "contributing to addiction" or in OD cases (the prescribers are usually held liable too). With all fills approved by a pharmacist it is their license and their clinical judgement at play when the choice to approve a prescription for dispensing is done. It's not about being the police, it's about exercising clinical judgement and saying no when you believe that is what's best (similar to a prescriber choosing not to issue a prescription). You should also know that one thing specifically worded in the law is that it is a pharmacist's legally bound duty to ensure all controlled substance prescriptions are for a valid purpose. Clinical abuse/misuse of medication is also one component of a prospective DUR which is to be performed when filling a prescription. Pharmacists aren't doling out criminal charges on early refills or issuing citations like a cop would, they are choosing in their clinical judgement how to use their license to dispense a medication.
     
  21. angelsplight

    angelsplight 2+ Year Member

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    You remind of that 1 professor I had who liked to show off his multiple licenses and in multiple states too but no one ever liked him because he always acted like he was better than everyone else so he became a running joke among all the students and other professors.

    That being said, what we do in the pharmacy I'm at is we refill it early BUT we don't dispense it till the day supply is suppose to be out unless it is for some special circumstances such as vacation or doctor approves. At least for my state law, we are allowed to dispense early refills up to 7 days early for controls.
     
    Last edited: Aug 12, 2017
  22. stoichiometrist

    stoichiometrist 5+ Year Member

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    That's assuming that the person even is a professional and not a junkie who created an account on SDN just to bash pharmacists for not refilling their drugs early.
     
  23. Digsbe

    Digsbe 5+ Year Member

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    I have 4 state licenses so unless he's got more than me according to that reasoning I am automatically right :D
     
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  24. lord999

    lord999 Moderator Emeritus 10+ Year Member

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    Here's your answer as that's not a rhetorical question to practicing pharmacists:
    http://graphics.latimes.com/prescription-drugs-part-three/

    Er, I'd be surprised if you practiced in the US, and I don't care how many "licences" you have, my licenses are "mine own" (in both the professional and personal contexts) to act in the appropriate ways that I am licensed in (including being the problem if I have to be to do the right thing). Actually, pharmacists are held professionally responsible in propria persona both at the state and the federal levels for both the accountability for the controlled substances supply chain (as in, variances above a certain level are revocable, and extreme variances are prosecuted) and whether a prescription is valid or not at the time of fill (not just at the time of written). There's a good deal of discretion allocated to pharmacists on that matter (and I would say that there is no honest RPh on this forum in US practice who has not doubted themselves on this matter before), but filling egregiously without consideration will result in a revocation. It's actually quite normal for the Pharmacist Board to defend pharmacists before the Board of Medical Examiners when conflicts happen on a physician that is trying to force a dispense against a refusing pharmacist, and almost always, the DEA will advocate in the pharmacist's favor the right not to dispense even for a legally written and valid prescription (the DEA and the DOJ have always taken the position that even with dishonest doubt, the pharmacist has discretion to deny for no reason whatsoever since the Harrison Act).

    So, there's still a debate whether a pharmacist has the right to deny dispensing on moral or religious grounds (birth control, euthanasia, intentional execution). However, for controlled substances, denying even valid cases to prevent drug control matters have always overrode patient care considerations even though it is heartless. Companies don't like excessive denial, but even the least ethical of companies do not want the DoJ finding an excuse to investigate the situation as with them, you are pretty much guilty until proven innocent.

    Yeah, there are some pharmacists who get off on the power of controlling the drug supply, I don't care and I hate those people too. But no physician or other prescriber is going to dictate to me what is or what isn't a valid prescription if I'm the one in the position to dispense. If prescribers really feel like punching the matter, they can administer the drugs themselves (and face the consequences of record keeping and liability), I'm not stopping them, and more power to them if they know the situation better than me. However, there's a reason why pain control physicians do not themselves dispense in a usual practice. They'd be red-flagged by the PDMPs and the DEA quota lists and be put out of business through scrutiny such that if you are going to have a successful practice, you need some sort of secondary check on the prescribing.
     
  25. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    Wrong, the DEA has raided and taken away pharmacies licenses for catering to pill-mill doctors. Now, why there might be a reason why someone needs a week early refill ONCE (like a trip out of the country), there is NO reason why they would need a week early refill every single month. Either they are taking too much of their medication (in which case they need to talk to their doctor and get an updated prescription with the increased directions....if appropriate), they are selling the drugs (which puts the pharmacy in liability), they are being careless with their drugs and allowing others in their household to use/steal them (in which case, it is 100% their own fault that they are always run out early) Whatever the reason, it's never appropriate for a pharmacist to repeatedly refill a prescription 1 week early each month.
     
  26. 6GodPharm

    6GodPharm

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    I do 1 day early (in case I need to order it so they still get it when it's due). Don't care about insurance or anything else letting it go 5-6 days early. I've had patients come in 2 weeks early say they "lost it" and even have the Dr office say it's ok to fill it lol take a hike front desk lady. If you didn't give a sh*t about your meds I don't either. Take better care.
     
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  27. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    Check with your state law:

    Pennsylvania Code: 27.18 Sub Section 2

    Do you want to appear before the State Board and argue what is reasonable? Chances are, if you do, it wasn't
     
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  28. lord999

    lord999 Moderator Emeritus 10+ Year Member

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    You can't use "It's Broad Street, Jake" as an excuse anymore? :)
     
  29. Mambo#5

    Mambo#5

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    Even if the prescriber says it's ok I don't fill it. Prescribers will always say it's ok. It's your license. If something happens your going to tell the pharmacy board.....the prescriber said it was ok to fill? If patient then says "but I always get my meds filled here"...you're going to tell the board he/she always.......

    It's your license.
     
  30. Mambo#5

    Mambo#5

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    Whether or not it goes through insurance is irrelevant. It could go through insurance 2 weeks early. The pharmacist must check to make sure it is not filled 2 days early period. If you have a hard time telling the person u won't fill it say.
    1. I've reached the maximum number of early refills that I'm able to do. This maximum varies month to month.
    2. I'm new and the board of pharmacy is closely watching my license, I'm sorry I can't fill it.
    3. I see you fill at Walgreens, it's best to keep filling at the same place.
    4. I see you've gone to two different urgent cares in one month it's best you get a primary care physician, I can't fill it.
    5. I don't have it.
    6. Other excuses for when it's not early... I have to call to verify this because we're getting a lot of fake scripts, we'll try our best to contact the doctor, I can't promise it will be done today since the doctors office isn't open.
    7. I don't feel comfortable filling this because....(if they argue just stand there n say I'm sorry I can't fill this in a nice way) if they ask for your name n license number give it to them, who cares?
    8. We've reached our limit for fills for this medication.
     
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  31. stoichiometrist

    stoichiometrist 5+ Year Member

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    Very true. The junkies will milk you for every opportunity to fill early but it's not like they'll defend you in front of the board if you do get into trouble.
     
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  32. Sine Cura

    Sine Cura 10 seconds or less 7+ Year Member

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    If the prescribers are gonna whine about pharmacists letting their patients refill so early, how about putting on "do not fill before" dates on your scripts? And don't post-date your written dates for your Rx either.

    I did read a decision from the California Board of Pharmacy about a PIC at Raley's who faced disciplinary action for him and his staff filling too many pill-mill Rx (yeah PICs are on the hook for the actions of your pharmacists too; I don't recall the staff pharmacists being disciplined), and I think the Raley's lost their DEA license. I can't find the decision right now. People should use a strict early-refill policy simply as a deterrent to the types of people who are always seeking to get early refills. You can get rid of a lot of bad apples that way

    And a bonus in California is about ~50% of written Rx are on non-compliant security forms so you can also use that as a basis for denial too. Most prescribers are clueless when it comes to this basic requirement, so maybe you should just report them to their respective licensing boards for being ignorant. You might as well write chicken scratch on a plain piece of paper if you can't even order the correct forms

    Edit: you really need to know your prescribers in your area and teach your staff too to avoid having to deal with shady types. You cannot just have tunnel vision and not know who your legit pain management clinics are, who are the cash-only pill mills, shady doctors at low-income clinics etc, not be able to recognize fake or forged scripts immediately
     
    Last edited: Aug 14, 2017
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  33. Digsbe

    Digsbe 5+ Year Member

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    I almost wish that a requirement for medical licensure was to pass the MPJE. It gets old having to explain laws and hear "but we've done it this way before."
     
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  34. Apotheker2015

    Apotheker2015 2+ Year Member

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    Prescribers can say it's ok, sing or recite a poem. It's up to the pharmacist. That's the final checkpoint. It's how the system was set up for a reason. If physicians were to dictate how we use our licenses, then we'd be some sort of PA's.

    Sometimes a pharmacist will look at the fill history over the last two months and say: "you know, your fill history shows that you should be good for another 7 days. I can get it ready for you in 5 days." And sure enough, the patient goes off on that RPH and they ask for me. That's when I pull the fill history for 6 to 9 months and do the math. "Actually, you should be good for the next 36 days. We will see you then". And I write the fill history all over that prescription. Done. Get out of my face. God... two years at this and listen to how disgruntled I sound already. Maybe I'll just become a PA.
     
  35. Apotheker2015

    Apotheker2015 2+ Year Member

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    I am sorry. Don't take this the wrong way but all that going in circles only gives patients more threads to pull and senseless reasons to call corporate or to go to the Store Manager who thinks he can rule the pharmacy without a pharmacist license and then take time away from you. LOL

    "You've gotten 5 consecutive early refills. Each early fill was 7 days early. At this time you should have a 35 day supply available to you. I am willing to fill this for you in 32 days from today."

    Done. Anything else tells them - I don't have a spine.

    "I don't feel comfortable" - never say that. Always hide behind company policy. If you DON'T, then you AREN'T following company policy. So if it's 2 days at CVS or 3 or whatever. Then say "Per CVS policy, bla bla bla." Because they will call corporate and twist what you said. I used to have the specific wording printed out and would read it to them verbatim whenever I was refusing to fill a C-II or an early fill.

    That tells them "It's come to this. I am this sick of people like you showing up with fake scripts and/or asking for early fills. Now GET OUT"

    I personally never override the date the system generates. That takes into account the last few months - maybe 3 months. I am sure corporate keeps track of who does excessive early refills. Patients try their luck all the time and keep ordering to see if it'll just slip by one of the pharmacists.
     
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  36. giga

    giga 10+ Year Member

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    Agreed. I am a big fan of not making **** up and just being upfront with patients. Especially when you have company policy and/or specific laws you can use to back up your decisions. If you can't honestly explain to a patient why you aren't going to fill a prescription for them, then maybe you should consider why you aren't filling the prescription rather than making up supposedly more palatable reasons. "Per company policy, I cannot refill this controlled substance until [enter date]. If you are completely out of your medication and need an emergency supply, please contact your doctor to send us a new prescription." If patients still give you a hard time, explain to them why the policy exists. If you don't understand why the policy exists, educate yourself first.

    Not to mention, some of your patients might actually be pharmacists themselves and will be able to see right through your dishonesty (speaking from personal experience here).
     
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  37. RxRetailRx

    RxRetailRx

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    MDApps:
    MDApps:
    We do three days early regardless insurance...
     

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