Doctor's mandating all or none on prescription approval.

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Rxnupe

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Ok today- a nurse calls in a prescription on vm for a patient as follows: Januvia 50mg: 1 po qd #20 Metformin 500mg 1 po BID #40, Atorvastatin 40mg: 1 po hs #20, Glyburide 5mg 1 po Bid #40 and Maxide 25mg 1 po qd #20(It appears MD was giving 20 day supply to gve ptient time to get an ppointment). The nurse firmly states that the MD is requesting an appointment asap and she then notes that the MD states:"patient must get all prescriptions or none"- she actually repeats that line twice.
My question: "is it legal for an MD to enforce a policy that the patient MUST get all or none?
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Last edited:
Rxnupe said:
Ok today- a nurse calls in a prescription on vm for a patient as follows: Januvia 50mg: 1 po qd #20 Metformin 500mg 1 po BID #40, Atorvastatin 40mg: 1 po hs #20, Glyburide 5mg 1 po Bid #40 and Maxide 25mg 1 po qd #20(It appears MD was giving 20 day supply to gve ptient time to get an ppointment). The nurse firmly states that the MD is requesting an appointment asap and she then notes that the MD states:"patient must get all prescriptions or none"- she actually repeats that line twice.
My question: "is it legal for an MD to enforce a policy that the patient MUST get all or none?
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My first inclination is no, that's not a legal order. Each script is a separate entry and can't be tied to the others... what happens if one or the other gets transferred?
 
There is nothing in my state's statutes that makes that a legally binging order, but I have had prescribes say both or neither in relation to pain meds + antibiotics and we honor that.
 
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It's like DAW-1 verbal vs. written, many states require it be written.

I can think of an easy workaround...pt transfers 2 of the 4 scripts he wants to another pharmacy, picks them up there. They DO have a legal right to transfer, right?
 
confettiflyer said:
It's like DAW-1 verbal vs. written, many states require it be written.

I can think of an easy workaround...pt transfers 2 of the 4 scripts he wants to another pharmacy, picks them up there. They DO have a legal right to transfer, right?
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You could always tell the pharmacist taking the transfer what the doctor said and leave it to their professional judgement wither to honor the 'order' or not.
 
All4MyDaughter said:
I doubt it's legally binding.

But someone should be arrested for the improper use of the apostrophe in the thread title. :smuggrin:
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Maybe it was edited, but it appears fine to me. OP is only talking about one doctor, so it is the doctor's mandate. I agree it is a bit awkward, as it is a verb being possessed, rather than an object. However, it seems sound in that sense.

Doctor's mandating all or none on prescription approval

is akin to:

A4MD's posting on SDN

Admittedly, adding an article before Doctor would be smoother, or perhaps they did mean "doctors" in general.
 
Ackj said:
Maybe it was edited, but it appears fine to me. OP is only talking about one doctor, so it is the doctor's mandate. I agree it is a bit awkward, as it is a verb being possessed, rather than an object. However, it seems sound in that sense.

Doctor's mandating all or none on prescription approval

is akin to:

A4MD's posting on SDN

Admittedly, adding an article before Doctor would be smoother, or perhaps they did mean "doctors" in general.
Click to expand...

I'm not totally sure. But it's definitely awkward.

In your example, 'posting' is acting as a gerund. Nerd alert! :D
 
owlegrad said:
You could always tell the pharmacist taking the transfer what the doctor said and leave it to their professional judgement wither to honor the 'order' or not.
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what? retail pharmacists have time to think about these things?

i'd be like "ooh higher script count, gotta make my DM happy"
 
Rxnupe said:
Ok today- a nurse calls in a prescription on vm for a patient as follows: Januvia 50mg: 1 po qd #20 Metformin 500mg 1 po BID #40, Atorvastatin 40mg: 1 po hs #20, Glyburide 5mg 1 po Bid #40 and Maxide 25mg 1 po qd #20(It appears MD was giving 20 day supply to gve ptient time to get an ppointment). The nurse firmly states that the MD is requesting an appointment asap and she then notes that the MD states:"patient must get all prescriptions or none"- she actually repeats that line twice.
My question: "is it legal for an MD to enforce a policy that the patient MUST get all or none?
Click to expand...

Why would you not comply with the doctor's order? It is no different than telling a customer they have to get both scripts when they walk up with vicodin and amoxacillin and only want the vicodin because they say that is all they can afford.

I would put it all back on the doctor if they had a problem with it. If money were an issue I would probably let them slide on the Januvia. The benefits are marginal and it is expensive as hell. The others I would stick to what the MD said and then get back to increasing your ready fill numbers and decreasing the wait time metric and the drive through timer and completing the PDQ, SQL, POS, and RD2 reports. (Sorry man I couldn't resist!).
 
owlegrad said:
There is nothing in my state's statutes that makes that a legally binging order, but I have had prescribes say both or neither in relation to pain meds + antibiotics and we honor that.
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When I worked retail, I had several customers who consistently "didn't have the money" for anything but their pain pills, and we would tell them that we had a new rule that they had to pick everything up, or nothing at all. (We sure did - FOR THEM!) And they didn't get ANYTHING, and didn't come back. :smuggrin:

We also had one guy who had multiple chronic health problems, and very good insurance, but he just didn't ever pick up his prescriptions, so we just put everything on hold, and when the doctor called and asked about him picking up his meds, told the doctor the truth. One weekend afternoon, we got something faxed to us from the ER, and the tech put it on hold. I told her to take it off hold, because he was going to want this. It was Phenergan suppositories, and sure enough, a few minutes later a truck pulled him with him in the passenger's seat, looking very green in the gills.

A4MD, I didn't know you're pregnant again. Congratulations! :love:
 
MountainPharmD said:
Why would you not comply with the doctor's order? It is no different than telling a customer they have to get both scripts when they walk up with vicodin and amoxacillin and only want the vicodin because they say that is all they can afford.
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I too fail to see how these are different scenarios.
 
MountainPharmD said:
Why would you not comply with the doctor's order? It is no different than telling a customer they have to get both scripts when they walk up with vicodin and amoxacillin and only want the vicodin because they say that is all they can afford.
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Because it's not a legal mandate. The whole getting vicodin AND amox is stupid too, they just throw out the amox leading to drug and money waste.


Completely hypothetical, but what if the pt doesn't maxide for a legit reason (wets teh bed). I don't give him any and he ends up in the ER with hyperglycemia. I'm sure the "his doctor told me what to do" excuse will fly with the board and/or court.

I'm not going to play the doctor's compliance officer
 
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I agree, it's not legally binding, but on the other hand, the doctor doesn't have to give her/him a script for anything, so I'd probably go along with it. Legally, I don't think you would get in trouble with either decision. I would try to find out ahead of time why the doctor wants all or none, and then you can tell the pt, your doctor said all or none because.... If the pt has a reason why (s)he won't get all the RX's, then I'd call back and let the office know that. I'm guessing the pt has ignored several "last refill until your next appt" warning, and is lucky the doctor is giving her/him anything
 
That Januvia is going to be a tough sell if the patient doesn't have insurance.
 
npage148 said:
Because it's not a legal mandate. The whole getting vicodin AND amox is stupid too, they just throw out the amox leading to drug and money waste.


Completely hypothetical, but what if the pt doesn't maxide for a legit reason (wets teh bed). I don't give him any and he ends up in the ER with hyperglycemia. I'm sure the "his doctor told me what to do" excuse will fly with the board and/or court.

I'm not going to play the doctor's compliance officer
Click to expand...

npage148 said:
Because it's not a legal mandate. The whole getting vicodin AND amox is stupid too, they just throw out the amox leading to drug and money waste.


Completely hypothetical, but what if the pt doesn't maxide for a legit reason (wets teh bed). I don't give him any and he ends up in the ER with hyperglycemia. I'm sure the "his doctor told me what to do" excuse will fly with the board and/or court.

I'm not going to play the doctor's compliance officer
Click to expand...

Who gives a **** if it is a legal madate or not? Are you 12 years old and in junior high? That is about how sophisticated your logic is.

How about we are all on the same team looking out for what is in the best interest of the patient. All of you are turning this into a pissing match between the pharmacist and the doctor. As if you will lose a piece of your fragile pharmacist ego if you comply with the doctor requests.

We are having a big discussion on continuity of care over in another thread. This thread proves my point wonderfully. We have such a disorganized and fractured healthcare system if it continues patient outcomes will never improve. This thread is a perfect example. The doctor wants the patient to have all the meds prescribed. Because the patient can choose to go where ever they want to get them filled they run into a pharmacist whose ego is bruised because "gasp" the doctor wants them to follow some very simply instructions. What a joke!
 
I'd probably comply... but we fill over 1,000/day and honestly, I don't have time to care.
 
Yeah guys, seriously who has the time to deal with situations like these? I'd just be like "ok doc" and that's it. They can't live patients lives nor can they tell me what to do. I can't even begin to think what the repercussions would be if in some rare case where the MD found out that the rph didn't enforce this dumb command. Would she report to the board of pharmacy? Please. They'd laugh at her.

Bottom line, we are pharm D's. it's time to start acting like one. Stop letting physicians teach you how to live or dictate what you're gonna sell. If the patient says I only want the pain medication or whatever, that's his choice. I (and many others I presume) really, really do not have the time of day to sit there and lose business while arguing with the patient telling them why I can't fill their prescription. If anything, the patient might call corporate and get me me trouble that wAy. The MD's dictation doesn't seem so binding now, does it? :)
 
fill 30 days of each, let them take whatever they want. big f'n whoop.. 20 days vs 30 days .. gimme a break .. too many doc's with god complexes, what is wrong with this country..
 
farmadiazepine said:
fill 30 days of each, let them take whatever they want. big f'n whoop.. 20 days vs 30 days .. gimme a break .. too many doc's with god complexes, what is wrong with this country..
Click to expand...

now you're prescribing without a license, different story bro
 
I would fill the 20 day supplies of all the RXs and make sure the patient knows he or she is NTBS. I would also tell the patient the doctor wants them to pick up all the meds, but if the patient doesn't want to or can't pay for them all, I won't force them to. Nor will I withhold meds. Patients have the right to refuse part of their treatment without being denied care completely.
 
All4MyDaughter said:
I would fill the 20 day supplies of all the RXs and make sure the patient knows he or she is NTBS. I would also tell the patient the doctor wants them to pick up all the meds, but if the patient doesn't want to or can't pay for them all, I won't force them to. Nor will I withhold meds. Patients have the right to refuse part of their treatment without being denied care completely.
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I think that's a fair approach to things. Though as a prescriber, I'd certainly want to know if patients aren't picked up all of the meds (especially in the previously mentioned antibiotics/narcotics example).
 
VA Hopeful Dr said:
I think that's a fair approach to things. Though as a prescriber, I'd certainly want to know if patients aren't picked up all of the meds (especially in the previously mentioned antibiotics/narcotics example).
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This is going to sound harsh to you, I'm sure, but you can discuss it with your patient at the next visit. Or have someone from your office call the pharmacy to check. We'll be happy to discuss it with them. There is no way I have time to call the prescriber every time someone doesn't pick something up. We reverse a lot of scripts because they are never picked up. I call (or fax) when the patient wants us to try to switch whatever they can't afford to another med, but not when the patient just never shows back up or doesn't want an alternative.
 
npage148 said:
I thought your job was what's wrong with pharmacy. What do we do when the PBM rejects the Januvia? Refuse to give them any of the medication? I mean all or nothing, right?
Click to expand...
They're on metformin and glyburide, shouldn't be a problem unless they have an idiotic 'generics only' contract.
 
or something like "must have documented trial of pioglitazone" or just a PA that is too slow being approved is enough to prevent the patient from getting any of their meds
 
Ackj said:
They're on metformin and glyburide, shouldn't be a problem unless they have an idiotic 'generics only' contract.
Click to expand...

Well, I didn't get into this aspect of it, but the patient described in the OP is on a stupid regimen for DM anyway. Lower doses of three meds? What's the point of that? Could probably increase the metformin to a dose that it at least therapeutic and go up on the glyburide. This would allow the patient to do without the Januvia. But often retail pharmacists don't have time to make such interventions, or you can't get the doctor to call you back, etc.
 
You mean you don't call doctors to discuss compliance AND how to optimize patients' DM regimen.

I don't know how much is truth but at one point I was told that Metformin 500 BID is a completely ineffective dose and that it's only used to start the patient on it (to minimize GI) and that if it's not increased soon after the doctor forgot to titrated up.
 
npage148 said:
You mean you don't call doctors to discuss compliance AND how to optimize patients' DM regimen.

I don't know how much is truth but at one point I was told that Metformin 500 BID is a completely ineffective dose and that it's only used to start the patient on it (to minimize GI) and that if it's not increased soon after the doctor forgot to titrated up.
Click to expand...

Sometimes I will call about optimizing regimens if the patient is interested and it's a prescriber I know is open to the discussion. I have a few like that. I have also written up recommendations and given them in writing for patients to discuss with their physicians at their next office visit.

And yeah, Metformin BID is low. The lowest effective dose is usually at least 1500 mg/day and most patients should be titrated to 1g BID. Doses above that don't give a lot of extra benefit, although you can go up to 2550 mg/day (850 mg TID).

Metformin 500 mg BID is a good prediabetes dose for prevention of type 2 diabetes in high risk patients.
 
All4MyDaughter said:
This is going to sound harsh to you, I'm sure, but you can discuss it with your patient at the next visit. Or have someone from your office call the pharmacy to check. We'll be happy to discuss it with them. There is no way I have time to call the prescriber every time someone doesn't pick something up. We reverse a lot of scripts because they are never picked up. I call (or fax) when the patient wants us to try to switch whatever they can't afford to another med, but not when the patient just never shows back up or doesn't want an alternative.
Click to expand...

I certainly don't expect it on every drug for every patient - we are neither of us the patient's mother. I meant primarily abx/narcotic combos - or really, any patient that's on chronic narcs who isn't picking up their other meds. That's more about protecting my ass than the patient.

Then again, as soon as I'm done with residency I plan to give up on any chronic narcotics so this will be a moot point.
 
VA Hopeful Dr said:
I certainly don't expect it on every drug for every patient - we are neither of us the patient's mother. I meant primarily abx/narcotic combos - or really, any patient that's on chronic narcs who isn't picking up their other meds. That's more about protecting my ass than the patient.

Then again, as soon as I'm done with residency I plan to give up on any chronic narcotics so this will be a moot point.
Click to expand...

I don't get that many patients with abx/narc combination who don't pick up both. That combination is most often seen (at least at my pharmacy) from the ED, so I definitely wouldn't bother calling.

I honestly don't call physician offices that often. It's usually pretty pointless. It's very rare to be able to speak to the prescriber, and you're leaving a message with a secretary or some HS graduate medical assistant who calls herself a "nurse" but isn't. I only call if there is a serious issue that requires a discussion with the physician. Otherwise, I send a fax and hope that he or she sees it.

It's really pretty crappy, TBH. Any physician can call my pharmacy at any time and I will get on the phone within a minute or two to talk with him/her. In fact, the law says only the pharmacist is allowed to do this. But any Tom/Dick/Harry/Sue working in the physician's office can act as the physician's agent for consults or calling in scripts. It's a challenge.
 
All4MyDaughter said:
I don't get that many patients with abx/narc combination who don't pick up both. That combination is most often seen (at least at my pharmacy) from the ED, so I definitely wouldn't bother calling.

I honestly don't call physician offices that often. It's usually pretty pointless. It's very rare to be able to speak to the prescriber, and you're leaving a message with a secretary or some HS graduate medical assistant who calls herself a "nurse" but isn't. I only call if there is a serious issue that requires a discussion with the physician. Otherwise, I send a fax and hope that he or she sees it.

It's really pretty crappy, TBH. Any physician can call my pharmacy at any time and I will get on the phone within a minute or two to talk with him/her. In fact, the law says only the pharmacist is allowed to do this. But any Tom/Dick/Harry/Sue working in the physician's office can act as the physician's agent for consults or calling in scripts. It's a challenge.
Click to expand...

I'm sorry girl, but that Joe Biden avatar creeps me out. And I like the guy. Lol.
 
All4MyDaughter said:
I

It's really pretty crappy, TBH. Any physician can call my pharmacy at any time and I will get on the phone within a minute or two to talk with him/her. In fact, the law says only the pharmacist is allowed to do this. But any Tom/Dick/Harry/Sue working in the physician's office can act as the physician's agent for consults or calling in scripts. It's a challenge.
Click to expand...

It's especially frustrating when doctors let people call in drugs who have no idea how to pronounce them and get grumpy when you ask them to spell the drug or get all flippant when you ask for clarification. "I guess so" or "Umm, i think it's..." is never an acceptable answer to me asking for clarification yet I hear it a bunch.

"What do you mean it's not cleomycin 500mg twice a day, that's what it says? I guess I can check with the doctor but it's going to take a while for me to get back to you, hmph"

I honestly like calling the ER the best with problems because I will always get to talk to a prescriber, they know what's going on, and they seem much more open to my suggestions.
 
All4MyDaughter said:
I don't get that many patients with abx/narc combination who don't pick up both. That combination is most often seen (at least at my pharmacy) from the ED, so I definitely wouldn't bother calling.

I honestly don't call physician offices that often. It's usually pretty pointless. It's very rare to be able to speak to the prescriber, and you're leaving a message with a secretary or some HS graduate medical assistant who calls herself a "nurse" but isn't. I only call if there is a serious issue that requires a discussion with the physician. Otherwise, I send a fax and hope that he or she sees it.

It's really pretty crappy, TBH. Any physician can call my pharmacy at any time and I will get on the phone within a minute or two to talk with him/her. In fact, the law says only the pharmacist is allowed to do this. But any Tom/Dick/Harry/Sue working in the physician's office can act as the physician's agent for consults or calling in scripts. It's a challenge.
Click to expand...

All fair points. That said (to make myself feel better), at my office whenever I get a note from the phone nurses (actually RNs at our office) that says its from a pharmacist, I will call the pharmacist myself as soon as I see the note.

That said, even among residents this is rare so I completely get where you're coming from with all of this.
 
npage148 said:
I thought your job was what's wrong with pharmacy. What do we do when the PBM rejects the Januvia? Refuse to give them any of the medication? I mean all or nothing, right?
Click to expand...

Thank God someone with some sense is involved in the process.

Typical statement by a doctor on a PA request - patient has failed all other oral diabetic medications and is on 500 units of Lantus evry night at bedtime. Patients is a morbidly obese type II and needs this medication or I will hold youand your company responsibly for the complications. Patient has been on Januvia samples for 6 weeks and has an A1C improvement from 16% to 15.99%. As you can see it is working and I demand its approval or I will call the newspaper, evening news, President Obama, and your mom and demand you be fired and held personnally responsible for any complications the denial causes.

The patient being a fat ass lazy type II that hasn't modified their lifestyle or diet and maybe takes the meds every other day or once a week mostly is not at fault. Its the PBM dening the PA for Januvia. Yep.....
 
MountainPharmD said:
The patient being a fat ass lazy type II that hasn't modified their lifestyle or diet and maybe takes the meds every other day or once a week mostly is not at fault. Its the PBM dening the PA for Januvia. Yep.....
Click to expand...

Wow, you can see all that on your screen?

Computers these days.
 
MountainPharmD said:
Typical statement by a doctor on a PA request - patient has failed all other oral diabetic medications and is on 500 units of Lantus evry night at bedtime. Patients is a morbidly obese type II and needs this medication or I will hold youand your company responsibly for the complications. Patient has been on Januvia samples for 6 weeks and has an A1C improvement from 16% to 15.99%. As you can see it is working and I demand its approval or I will call the newspaper, evening news, President Obama, and your mom and demand you be fired and held personnally responsible for any complications the denial causes
Click to expand...
Reading this is even funnier after you've seen some that are like this. As has been stated elsewhere, nobody knows what it's like on the "other side." My favorite was "Why in the world would this patient's test strips require PA? This is ridiculous and a barrier to patient health! Approve this immediately!" We had no such PA, no idea why they sent that in to us. The member never even had a submitted claim for strips, so it couldn't have been a misinterpretation of early refill or anything like that either.

Honorable mention goes to a PA for Aciphex. Diagnosis: GERD. Other PPIs tried: (blank, claims history shows none). Other info: "This is an essential medication, interruption of this therapy will lead to destabilization, hospitalization, and death." Pretty sure nobody has died from their previously unmedicated GERD getting a trial of omeprazole.
 
Ackj said:
Reading this is even funnier after you've seen some that are like this. As has been stated elsewhere, nobody knows what it's like on the "other side." My favorite was "Why in the world would this patient's test strips require PA? This is ridiculous and a barrier to patient health! Approve this immediately!" We had no such PA, no idea why they sent that in to us. The member never even had a submitted claim for strips, so it couldn't have been a misinterpretation of early refill or anything like that either.

Honorable mention goes to a PA for Aciphex. Diagnosis: GERD. Other PPIs tried: (blank, claims history shows none). Other info: "This is an essential medication, interruption of this therapy will lead to destabilization, hospitalization, and death." Pretty sure nobody has died from their previously unmedicated GERD getting a trial of omeprazole.
Click to expand...

Unless there was a concern of interaction with omeprazole that rabeprazole doesn't have. I would definitely AT LEAST get more info about the situation. Maybe the patient tried OTC omeprazole without consulting a pharmacist or doctor first...who knows. I always ask for as much info as possible before just rolling my eyes at it.
 
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