Insulin pen, box: open box or not? Rite Aid Old Memo of 2013?

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HelpfulPharmer1

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Folks, my friend recalls from memory that Rite Aid sent out a memo in 2013 about them getting audited and fined over 1 million dollars for giving too much insulin pens as 1 box and bill for just 28 days.

The argument among pharmacist was that: box of "insulin pen" is not break-able.
However, because of the audit and penalty, Rite Aid wanted pharmacies to break box and dispense enough insulin pens. Still, many did not recall reading or seeing that memo.

Anyone can please find that old memo and post it here to settle the argument? The memo was sent from Corporate Headquarters to all pharmacists in 2013. I am sure with 100 thousands employees, someone can find that memo and post it here (because Rite Aid only allows old email to be kept within a few short weeks.)

That memo is gone now. But the argument among pharmacists is still going on.

Like it or not, we have to follow the policy of the company that pays our check.

If someone can please find that memo and post the memo here, we would really appreciate your help.

Thanks from a bunch of confusing and arguing pharmacists and technicians.....

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I don't have the memo unfortunately but I distinctly remember Nexgen listing lantus solostar as quantity of 15ml and it autorounding anything not in 15ml increments next highest 15ml interval, this was back in 2011ish. Many people as a result got in a habit of rounding to the nearest box, obviously this is not the case now and 3ml increments are used but when the change happened I'm not sure - likely a result of the disciplinary case you mentioned.
 
Team Open Box until I die. Seriously, it makes no sense why you would give someone a full box when 2 pens is a 30 day supply.
 
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Just ask your DM what you should be doing. I'v never seen a box opened and I'm pretty sure the computer at CVS tells you they should be dispensed in 15ml increments, however I personally don't see why a box couldn't be opened and I don't see anything on the box itself saying it can't be split.

If the doctor writes for a 90 day supply and 5 boxes makes an 87 day supply, do you:

1. Dispense 5 boxes as 87 day supply
2. Dispense 5 boxes as 90 day supply
3. Dispense 6 boxes as 90 day supply
4. Dispense 6 boxes as 104 day supply

(Assuming you are not breaking boxes)

I think everyone who isn't opening boxes agrees option 3 is correct right?
 
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1. Dispense 5 boxes as 87 day supply. If insurance will only cover 90 exactly then break open a box. 5 boxes and 1 pen.

Now try this: If the doctor writes for a 30 day supply and 1 box makes a 150 day supply, do you:

1. Dispense 1 box as 30 day supply
2. Dispense 1 box as 150 day supply
3. Dispense 1 pen as 30 day supply.
 
1. Dispense 5 boxes as 87 day supply. If insurance will only cover 90 exactly then break open a box. 5 boxes and 1 pen.

Now try this: If the doctor writes for a 30 day supply and 1 box makes a 150 day supply, do you:

1. Dispense 1 box as 30 day supply
2. Dispense 1 box as 150 day supply
3. Dispense 1 pen as 30 day supply.

I can tell you which option makes sense vs which option will happen at my pharmacy :) Btw I choose the 87 day supply and the pharmacist changed it to 6 boxes 90 day supply this week...

I guess CVS will profit more and the patient will have plenty of insulin at least.
 
1. Dispense 5 boxes as 87 day supply. If insurance will only cover 90 exactly then break open a box. 5 boxes and 1 pen.

Now try this: If the doctor writes for a 30 day supply and 1 box makes a 150 day supply, do you:

1. Dispense 1 box as 30 day supply
2. Dispense 1 box as 150 day supply
3. Dispense 1 pen as 30 day supply.

I'd do option 2 then adjust day's supply per insurance rejection to whatever their max is. In Walmarts escribe the day's supply is mostly zero on the rx because they never fill that part out.
 
I was still editing lol

I'm quick like a fox! But my point remains the same. If 30 days is max then why is it appropriate to give them 4 free months worth of medication?
 
I'm quick like a fox! But my point remains the same. If 30 days is max then why is it appropriate to give them 4 free months worth of medication?

My job during school was LTC and we did open insulin pens and the quantity on the labels was always by 3 mL, but at my retail rotations and now every Walmart I've worked at or floated at, they don't open the pen boxes so I don't. They all bill for the full box and what the day supply would be with the current dose so I don't think it's fraud.
 
I'm quick like a fox! But my point remains the same. If 30 days is max then why is it appropriate to give them 4 free months worth of medication?


Because that is how it comes.

Patients using 2 sprays daily of Flonase whose insurance will only cover 30 days supply get a free month every time they fill an Rx.
 
Because that is how it comes.

Patients using 2 sprays daily of Flonase whose insurance will only cover 30 days supply get a free month every time they fill an Rx.

Apples and oranges. You cannot break a vial of Flonase.
 
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So it's appropriate to give the patient 4 free months of medication?

So, what happens when a patient is to take 1/4 tablet every other week and insurance max is 30 days? Do you give them a half tablet?

Assuming you'd give them a whole tablet, is it appropriate to give the patient a free month's worth of medication?

Assuming you say this is comparing apples to oranges, consider the amount of effort it takes to split a tablet vs. opening a box of insulin pens and appropriately repackaging them and you'll find this to be less of a task than breaking a box of insulin pens.

I'm pretty sure this is all more of a grey area than as black and white as everyone is pretending it to be.

Consider when a patient takes 8 tablets of Levothyroxine per week. Do you give them 32 tablets per 28 days because it doesn't change every fill even though their insurance will pay for 30 days worth? Or do you give them 34 tablets and assume the remaining 2 days are both 1-tablet-days? Or do you give them 35 tablets and assume one of them is a 2-tablet-day? Or do you change the quantity every 7th month to be as accurate as possible (based on the medication calendar you've apparently forced them to bring in and review with you)?

Or do you just say it's a stupid debate with no answer and the god damned phone is screaming "THREE PHARMACY CALLS! LANE TWO!" and you're about to pass out because your blood sugar is 35 mg/dL and haven't had any food in 14 hours and decide that that you do not have time for this idiocy and give them whatever gets them to leave you alone the fastest within reason?
 
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So, what happens when a patient is to take 1/4 tablet every other week and insurance max is 30 days? Do you give them a half tablet?

Assuming you'd give them a whole tablet, is it appropriate to give the patient a free month's worth of medication?

Assuming you say this is comparing apples to oranges, consider the amount of effort it takes to split a tablet vs. opening a box of insulin pens and appropriately repackaging them and you'll find this to be less of a task than breaking a box of insulin pens.

I'm pretty sure this is all more of a grey area than as black and white as everyone is pretending it to be.

Consider when a patient takes 8 tablets of Levothyroxine per week. Do you give them 32 tablets per 28 days because it doesn't change every fill even though their insurance will pay for 30 days worth? Or do you give them 34 tablets and assume the remaining 2 days are both 1-tablet-days? Or do you give them 35 tablets and assume one of them is a 2-tablet-day? Or do you change the quantity every 7th month to be as accurate as possible (based on the medication calendar you've apparently forced them to bring in and review with you)?

Or do you just say it's a stupid debate with no answer and the god damned phone is screaming "THREE PHARMACY CALLS! LANE TWO!" and you're about to pass out because your blood sugar is 35 mg/dL and haven't had any food in 14 hours and decide that that you do not have time for this idiocy and give them whatever gets them to leave you alone the fastest within reason?

Lucky for me I'm a hospital pharmacist who doesn't have to deal with that but I work quite a bit at our outpatient pharmacy. We always break boxes of insulin pens because that's what insurance requires. Maybe you guys should read up on the contracts you sign with third parties? Your pill comment is great, unfortunately it has been addressed by insurance auditors as appropriate. Those same auditors are the ones who say that if one pen lasts 30 days then you better be dispensing one pen as a 30 day supply.
 
Lucky for me I'm a hospital pharmacist who doesn't have to deal with that but I work quite a bit at our outpatient pharmacy. We always break boxes of insulin pens because that's what insurance requires. Maybe you guys should read up on the contracts you sign with third parties? Your pill comment is great, unfortunately it has been addressed by insurance auditors as appropriate. Those same auditors are the ones who say that if one pen lasts 30 days then you better be dispensing one pen as a 30 day supply.
I don't sign any insurance contracts. Do you? What kind of hospital would allow that? Benjammin General?
 
I don't sign any insurance contracts. Do you? What kind of hospital would allow that? Benjammin General?

Our outpatient pharmacy goes through the rank. You think it's impossible to read those? LOL whatever you say.
 
Our outpatient pharmacy goes through the rank. You think it's impossible to read those? LOL whatever you say.
If you work as a staff pharmacist for one of the two largest pharmacy chains in the country, yes. I do think it's impossible.
 
If you work as a staff pharmacist for one of the two largest pharmacy chains in the country, yes. I do think it's impossible.

Well, I do not. Lucky me, huh?
 
Sure let me just ask to read the insurance agreement I signed at CVS, that makes sense. How about this, can you post the insurance agreement you signed that says to break insulin boxes? That would be great, thanks.
 
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Also, the pill splitting analogy is flawed because you can't bill for 1/2 a tablet but you can bill for one pen (although I do not agree with breaking boxes).
 
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Sure let me just ask to read the insurance agreement I signed at CVS, that makes sense. How about this, can you post the insurance agreement you signed that says to break insulin boxes? That would be great, thanks.

It doesn't say I can break insulin boxes, it gives a list of things I can bill. That includes a WHOLE tablet, a box of insulin, and an insulin pen. I'd have to do a lot of censoring but I'm willing to do it.
 
Every insurance I've called says it's ok to give one box for 30 day supply. Wag system won't even allow putting in partial box.
 
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Every insurance I've called says it's ok to give one box for 30 day supply. Wag system won't even allow putting in partial box.

What if a 30 day supply of Lantus is 8 pens? You better break that box if you're billing for a 30 day supply.
 
Also, the pill splitting analogy is flawed because you can't bill for 1/2 a tablet but you can bill for one pen (although I do not agree with breaking boxes).
Sure you can. Why wouldn't you be able to?
 
Hmm, you know what, I have never tried, maybe you are right!
You definitely can if you enter it as a compound (a one ingredient one if need be)
 
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I can tell you which option makes sense vs which option will happen at my pharmacy :) Btw I choose the 87 day supply and the pharmacist changed it to 6 boxes 90 day supply this week...

I guess CVS will profit more and the patient will have plenty of insulin at least.

Folks, put yourself in the shoe of a small pharmacy owner and every dollar you make is sweats and tears.

The focus is: Do we lose money through audits? In this discussion forum, I looked back to past posts and I have seen replies showing no audits happened and also seen replies showing audits did happen and owners lost money. Can someone please provide some scanned documents to settle the arguments.

I agree with your practice. No problem with me.

Open the box. You like it that way? I respect your decision.
Not open the box. You like it that way? I respect your decision.

As a small business owner, which way actually cost you money through audits by nasty greedy auditors?

Rite Aid announced to the whole corporation that Rite Aid lost over 1 million dollars because pharmacist gave whole box and billed as 28 days. From now on, company policy is to break open the box and give enough pens.

We are looking for that evidence, the memo was around 08-2013. Please share it here. Thank you very much.

Any document, folks?
 
What if a 30 day supply of Lantus is 8 pens? You better break that box if you're billing for a 30 day supply.
This doesn't make sense, why would I ever open a second box? Give two boxes and put the correct day supply.
 
Folks, put yourself in the shoe of a small pharmacy owner and every dollar you make is sweats and tears.

The focus is: Do we lose money through audits? In this discussion forum, I looked back to past posts and I have seen replies showing no audits happened and also seen replies showing audits did happen and owners lost money. Can someone please provide some scanned documents to settle the arguments.

I agree with your practice. No problem with me.

Open the box. You like it that way? I respect your decision.
Not open the box. You like it that way? I respect your decision.

As a small business owner, which way actually cost you money through audits by nasty greedy auditors?

Rite Aid announced to the whole corporation that Rite Aid lost over 1 million dollars because pharmacist gave whole box and billed as 28 days. From now on, company policy is to break open the box and give enough pens.

We are looking for that evidence, the memo was around 08-2013. Please share it here. Thank you very much.

Any document, folks?
If it happened to them then why have I never seen an audit before?
 
This doesn't make sense, why would I ever open a second box? Give two boxes and put the correct day supply.

It makes perfect sense. Patient's insurance will only pay for a 30 day supply. Dr directions show that 8 pens is a 30 day supply. You don't give them two boxes, you give them one box plus 3 pens.
 
You give them one box with correct supply and either call md to add refill or just add one.

You do realize that most directions won't come out perfect even if you break open a box right? So who gets screwed the patient or insurance?
 
"If insurance will only cover 30 days"

"If insurance will only cover 90 days"

99% of the time it will be UP to 30 days or UP to 90 days.

Ex: Victoza 3-pak not covered at 1.8 mg/day but Victoza 2-pak is? Give a 2-pen box and put in 20 days.

Taxpayers and responsible premium payers are screwed because of jagoffs who don't give a crap about their health.

If only one pen lasted 28/30 days. "1 vial OK per MD" and get a script for insulin syringes
 
It makes perfect sense. Patient's insurance will only pay for a 30 day supply. Dr directions show that 8 pens is a 30 day supply. You don't give them two boxes, you give them one box plus 3 pens.
give 1 box with an 18 day supply with 1 refill. problem solved
 
Relevant sections out of the Express Scripts (/Medco)Network Provider Manual which you can get by logging in to their website: https://host1.medcohealth.com/medco/prc/index.jsp

The submitted NDC must be the complete NDC of the medication dispensed, including the package size. For example, if ten (10) or more vials of Pergonal® or similar products are dispensed at one time, the NDC number of the 10-pack must be submitted. Drug products contained in “unbreakable” packages as determined by the FDA must be in their original packaging and dispensed as a whole unit. Examples include oral contraceptives, Accutane 10-packs, etc. The Network Provider must use actual metric package sizes when available. If the metric measurement is not available, the following standard conversions should be used:
o One fluid ounce = 30 ml.
o One pint = 480 ml.
o One liter = 1000 ml.
o One ounce = 30 g.
o One pound = 454 g.

2.13 Days Supply
The exact number of consecutive days supply must be submitted, with the calculation based on the metric quantity prescribed and the Prescriber’s exact written directions. If the Prescriber does not provide exact directions, or writes “as directed” or “prn”, or writes directions where a consecutive days supply cannot be calculated, Network Provider must call the Prescriber or ask the Member for the directions, document such directions on the prescription, initial the same, and submit the exact days supply based on those directions and the quantity prescribed. Prescriber’s signature on the prescription does not translate into an assumed days supply. Stated another way, days supply must always be calculated based on the information on the prescription and must never be assumed.
-------------------------------
However, the following exceptions are listed under "6.5 Discrepancy Glossary:"
-------------------------------
For products dispensed in unit of use packaging, allow for “as directed” with the following guidelines:
• If no specific quantity indicated, Network Provider must call Prescriber for quantity or directions for use to calculate quantity.
• If specific quantity is given and the smallest available package size is prescribed, dispense with “as directed” for a 30-day supply. If quantity indicated is not smallest package size, the Network Provider must document directions for use.
• As Directed may be used in the following conditions (all others require specific directions)
o Test Strips and Lancets – one box of 100 for 30 days
o Insulin Vials – up to 2 vials for a 30-day supply
o Insulin Syringes – 1 box of 100 for a 30-day supply (or 9 packages of 10)
o Insulin Cartridges/Pens – 1 box for 30 days
o Pen Needles – 1 box for 30 days
For oral solids dispensed as individual tablets, specific directions for use are required, except:
• Warfarin products: If dispensed as a 1 for 1 ratio, dispense with “as directed” (e.g. 30 for 30 days, 90 for 90 days)
• Steroids: When directions are “as directed per tapering dose,”
• All oral solids dispensed in manufacturer’s original packaging must have directions for use except:
o Drugs on current Quantity Level Limits (QLL) list (e.g. Viagra, Imitrex). If QLL is exceeded, must have directions for use.
o Manufacturers’ packaging has pre-printed patient instructions (e.g. Fosamax).
--------------------------------
Back to "2.13 Days Supply"
--------------------------------
Should the days supply submitted exceed the Sponsor’s Prescription Drug Program’s limitation, Network Provider will receive a “days limit = ‘x’ ” online message. Please do not reduce days supply without also reducing quantity. In such case, based on the Prescriber’s directions, reduce the quantity dispensed to the Member proportional with the reduction in days. Failure to reduce a quantity when reducing a days supply may result in a recoupment of the over-billed amount upon audit.

2.14 Quantity
The exact metric quantity (as defined by NCPDP) of the drug prescribed must be submitted. Network Provider should not reduce the quantity unless required due to a “quantity limit = x” online message. In this case, reduce the quantity accordingly. Quantity must also be reduced when receiving a “days limit = x” online message. In such case, calculate the new metric quantity based upon the Prescription Drug Program’s days supply limit and the Prescriber’s exact written directions for use. Failure to reduce a quantity when reducing a days supply will result in a recoupment of the over-billed amount upon audit. In cases where the drug prescribed is an unbreakable package, reduce the quantity to the smallest package size available closest to the Prescription Drug Program’s days supply limit and enter the maximum days supply allowed by the Sponsor’s Prescription Drug Program.
-----------------------------

So I think we should investigate whether a box of insulin pens is considered “unbreakable” by the FDA.
 
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What if a 30 day supply of Lantus is 8 pens? You better break that box if you're billing for a 30 day supply.
It makes perfect sense. Patient's insurance will only pay for a 30 day supply. Dr directions show that 8 pens is a 30 day supply. You don't give them two boxes, you give them one box plus 3 pens.
No, you'd give one box for an 18 day supply. Two boxes is a 36 day supply, so billing that for 30 days wouldn't be acceptable.

How do you dispense test strips? Do you break open the box and dispense the individual vials, or individual strips? Test once daily = 30 strips. Not all manufacturers have NDCs for 25 count, so you can't do #25/25 days.
 
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Yeah, I'd just give the whole box and put the sig as use as directed and print out another label with the actual instructions with amount of units to use/frequency.
Use as directed = instant chargeback. Goodbye $400 per fill.
 
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Not the Rite Aid memo, but here's CVS Caremark audit tips. Boxes cannot be broken and use as directed isn't allowed.
 

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Not the Rite Aid memo, but here's CVS Caremark audit tips. Boxes cannot be broken and use as directed isn't allowed.


Thank you very much for supplying the CVS audit prevention guide. From your guideline, I extracted the section about insulin box and uploaded back here. The CVS guide wrote below section for insulin box and I quote:
''ALWAYS ALLOW MANUFACTURER'S SMALLEST PACKAGE SIZE AND DO NOT BREAK PACKAGE REGARDLESS OF DAYS SUPPLY''.

Let's see what Rite Aid Memo shows. Anyone found the Rite Aid Memo? Please look deeper in your corporate email around 08-2013 and upload Rite Aid Memo here or send anonymously to this email address ij201220132014 AT gmail DOT com and I will upload here.


CVS AUDIT GUIDE, OKAY TO GIVE FULL BOX INSULIN PENS.png

In original picture, you can also read this first line:
The CVS Caremark audit department is providing basic information, on appropriate billing of diabetic supplies and insulin to help prevent audit discrepancies.

Below sentence is quoted from bottom of above picture:
''Always allow manufacturer's smallest package size and do not break package regardless of Days Supply''.
 
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I'm several months late jumping on this band wagon. I'm a fairly new diabetic patient (April of this year ironically) and also a new pharmacist as of May. My monthly insulin use (Lantus Solostar) started at 10 units daily and titrate up until BG is at goal level. My wife picked up the Rx and came home with a box of 5 pens. I ended up titrating to 14 units daily so monthly insulin use is now 140 units.

When I went to refill the Rx after I ran out of insulin (nearly 6 months later) I was given 2 pens. I was confused by this because the pharmacy I work for (different from the pharmacy I get Rxs at) never breaks boxes of pens. It was at this time I saw the Rx was written for a quantity of 6. To me, 6mL = 2 pens. Makes sense. But why is this pharmacy breaking boxes and another pharmacy is not?

I literally just got of the phone with Sanofi. They do not recommend the boxes be broken. They are sold to the pharmacy as one unit and should therefore be sold to the customer as one unit. However, since the pharmacy now owns the product they can do with it what they wish and is it not illegal for them to break the box and sell the pens individually.

Now I'm left wondering if this "recommendation" is nothing more than a way for Sanofi to sell more boxes on insulin pens to pharmacies. Because using this same logic of "we sold it as a whole unit, it should be dispensed as a whole unit" - If a customer comes into a pharmacy with an Rx for 30 tablets of drug x, and you have a bottle on the shelf that contains 100 tablets of drug x, shouldn't the customer get the entire unopened bottle of 100 tablets? After all, it was sold to the pharmacy as one unit and should therefore be sold to the customer as one unit.
 
I'm several months late jumping on this band wagon. I'm a fairly new diabetic patient (April of this year ironically) and also a new pharmacist as of May. My monthly insulin use (Lantus Solostar) started at 10 units daily and titrate up until BG is at goal level. My wife picked up the Rx and came home with a box of 5 pens. I ended up titrating to 14 units daily so monthly insulin use is now 140 units.

When I went to refill the Rx after I ran out of insulin (nearly 6 months later) I was given 2 pens. I was confused by this because the pharmacy I work for (different from the pharmacy I get Rxs at) never breaks boxes of pens. It was at this time I saw the Rx was written for a quantity of 6. To me, 6mL = 2 pens. Makes sense. But why is this pharmacy breaking boxes and another pharmacy is not?

I literally just got of the phone with Sanofi. They do not recommend the boxes be broken. They are sold to the pharmacy as one unit and should therefore be sold to the customer as one unit. However, since the pharmacy now owns the product they can do with it what they wish and is it not illegal for them to break the box and sell the pens individually.

Now I'm left wondering if this "recommendation" is nothing more than a way for Sanofi to sell more boxes on insulin pens to pharmacies. Because using this same logic of "we sold it as a whole unit, it should be dispensed as a whole unit" - If a customer comes into a pharmacy with an Rx for 30 tablets of drug x, and you have a bottle on the shelf that contains 100 tablets of drug x, shouldn't the customer get the entire unopened bottle of 100 tablets? After all, it was sold to the pharmacy as one unit and should therefore be sold to the customer as one unit.
14 * 30 = 140?
 
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I do not break a box of pens or a split a tube of ointment. There is a single set of instructions that come in the package that indicates it is to sold as a single unit. I also have over 30 years of community experience and I have not seen an audit charge back for not breaking a box of pens. Not a single time. The ONLY time there was an issue was with Levemir where the days supply was reported as 30 and the real days supply was longer and we inadvertently placed it on Readyfill and filled it for months in a row. Also remember that all of the insulins go bad a certain number of days after opening. No matter what the calculation says a bottle of lantus cannot have a days supply greater than 28.
 
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All multi dose vials also should have not have greater than 30 day supply because they lose sterility 28 days later per USP after puncturing
 
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When I worked LTC we broke open pen boxes for lantus solostar, but at 10 walmarts I've worked at, no one does, EVER.
 
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I have never heard of breaking open insulin pen boxes, other than on this board. As others have stated, the pens come with paper directions....there is only 1 set of directions per box, it seems obvious the pens should be dispensed in the unbroken box. I have also never heard of getting a chargeback for dispensing a box (where the chargebacks come is when someone gives out 2 boxes where were a 36 day supply and rounds down to 30 days....in this case, the person must be given 1 box as an 18 day supply.)
 
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Try entering less then a box, wag won't allow it.
 
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