More than 30 Zolpidem

[ResCon]

So, patient comes in with a script for Zolpidem w/ a written qty of 34 for 30 days. Sig states that patient can occasionally take a half tab. However, insurance will only cover 30 every month. I figure, okay, let's let the patient just pay cash for the extra 4, and we're good. To my surprise the PIC had a huge problem with this, saying that we can only dispense whatever insurance covers for controlled substances.

My problem is: wouldn't this be contrary to what the doc intended on the script? We're basically deciding what dose the patient is going to get, regardless of what the doc has indicated. What is insurance offered no coverage? Would we dispense nothing? Assuming patient is willing, why couldn't we just charge cash for the extra 4?

Have any of you all ever encountered such a policy WRT controlled substances and insurance quantity limits? (this is WAG, btw). When patient comes in, I'm trying to think of a way to explain it without it sounding like total nonsense.

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[Momus]

Your PIC is a dumb ass >_>;

 

[Digsbe]

You don't have to dispense only what insurance covers. You can bill the 30 on insurance and bill the remaining 4 as cash. What reason is he citing for not allowing this?

 

[Rockinacoustic]

When patient comes in, I'm trying to think of a way to explain it without it sounding like total nonsense.

You should have the patient talk to the PIC then because it sounds like total nonsense.

 

[Carboxide]

So, patient comes in with a script for Zolpidem w/ a written qty of 34 for 30 days. Sig states that patient can occasionally take a half tab. However, insurance will only cover 30 every month. I figure, okay, let's let the patient just pay cash for the extra 4, and we're good. To my surprise the PIC had a huge problem with this, saying that we can only dispense whatever insurance covers for controlled substances.

My problem is: wouldn't this be contrary to what the doc intended on the script? We're basically deciding what dose the patient is going to get, regardless of what the doc has indicated. What is insurance offered no coverage? Would we dispense nothing? Assuming patient is willing, why couldn't we just charge cash for the extra 4?

Have any of you all ever encountered such a policy WRT controlled substances and insurance quantity limits? (this is WAG, btw). When patient comes in, I'm trying to think of a way to explain it without it sounding like total nonsense.

From what you're saying it sounds like 34 would be more than a 30 day supply. Why did you think it was only 30 days?

 

[bacillus1]

There is now guidance by the FDA to lower the max dose of zolpidem, especially if the patient is female. Maybe the PIC was thinking from a safety standpoint? From your description, it doesn't sound like it, but maybe it could be the case.

 

[Star30z]

Sounds like you would have to prepare the rx to be sold for #30 and billed to insurance. Then prepare a second rx for #4 and sell it as cash. That would look like the PIC sold a RTS on a controlled substance, I wouldn't do it! I would ask the pt to pay cash for all 34 or take #30 with insurance... His pick.

 

[BenJammin]

Why not partial fill it for 30?

 

[Corpseman]

Why not partial fill it for 30?

Because that wouldn't be a full 30 day supply for this patient.

 

[Ackj]

From what you're saying it sounds like 34 would be more than a 30 day supply. Why did you think it was only 30 days?

Depends how it's worded. OP states "occasionally take half tab." Which means you should be dispensing less than 30 in theory. However, I think they might mean "occasionally take an additional half tab." In order for it to be exactly 30 days, there would need to be 8 times they take 1.5 tabs instead of one. If this is a patient who has been on 10mg for a while, and with the new dosing guidelines are now taking 5mg, I can definitely see this scenario. Devil's in the details though, especially on stuff like this.

Most likely, though, the PIC is just being stubborn. What about those plans that cover 30 zolpidem every 60 days? He won't fill it every month?

 

[pezdispenser]

Assuming you meant occasionally take a half tab in addition to one tab nightly.

Insurance and the days supply you enter into the computer is just a payment issue. It's not the law.

I have no problems dispensing #30 through insurance and cashing out #4. I don't feel like it's RTS because the prescriber allowed the patient to have in possession up to 34 tablets at a time, dispensed every 30 days.

The partial fills do not count as a refill under the DEA's 'maximum 5 refills/6 months' rule.

For CIIs, check with your state board. Some states allow it, and some don't.

 

[Carboxide]

Assuming you meant occasionally take a half tab in addition to one tab nightly.

Insurance and the days supply you enter into the computer is just a payment issue. It's not the law.

I have no problems dispensing #30 through insurance and cashing out #4. I don't feel like it's RTS because the prescriber allowed the patient to have in possession up to 34 tablets at a time, dispensed every 30 days.

The partial fills do not count as a refill under the DEA's 'maximum 5 refills/6 months' rule.

For CIIs, check with your state board. Some states allow it, and some don't.

This.

If the sig said, "Take 1 OR 1/2 tablet by mouth nightly" then dispensing 34 is wrong, your PIC is right, you early filled a control.

If the sig said "Take 1 tablet by mouth nightly; may take an additional 1/2 tablet twice a week as needed" then 34 is a 30 day supply and there is no problem.

The key for the second situation is that you MUST bill the 30 as a NOT 30 day supply. The 30 is a 26 or 27 day supply based on how you want to do it. In that situation they are getting a 3.5 (or 3, to round) day supply for today and immediately refilling for a 27 day supply, 3 days early, which is acceptable.

 

[lactonerx]

1 tab qhs + ½ twice weekly PRN qty #34 is a 30d supply. If insurance doesn't auth more than 30 tabs in 30 days you may need prior auth since insurance thinks this is 1.13 tab/day dosing.

If you do decide to sell #30 on insurance the days of supply is 26. Making the days of supply 30 for #30 and selling #4 cash with days of supply 4 is incorrect.

 

[owlegrad]

1 tab qhs + ½ twice weekly PRN qty #34 is a 30d supply. If insurance doesn't auth more than 30 tabs in 30 days you may need prior auth since insurance thinks this is 1.13 tab/day dosing.

If you do decide to sell #30 on insurance the days of supply is 26. Making the days of supply 30 for #30 and selling #4 cash with days of supply 4 is incorrect.

What do you do if the insurance will only pay for a 30 DS and will not allow more than 30/30?

I get that a lot for unit of use items and the insurance rejects due to only allowing DS of 30.

 

[lactonerx]

What do you do if the insurance will only pay for a 30 DS and will not allow more than 30/30?

I get that a lot for unit of use items and the insurance rejects due to only allowing DS of 30.

I see lots of PPIs and Cymbalta run into this kind of problem and they only seem to be resolved with prior auth. Making a change to DS could be interpreted as fraud during an audit, such as 60 capsules PPI BID billed as a 60d supply b/c ins doesn't cover more than 30 capsules in 30 days (which is also a disservice to the patient if they are going to need refills)

 

[npage148]

such as 60 capsules PPI BID billed as a 60d supply b/c ins doesn't cover more than 30 capsules in 30 days (which is also a disservice to the patient if they are going to need refills)

I get into a murderous rage when I need to fix someone billing a #60 bid as a 60days supply because they don't want to be bothered with calling the dr/doing a pa/etc.

 

[BidingMyTime]

If the sig said, "Take 1 OR 1/2 tablet by mouth nightly" then dispensing 34 is wrong, your PIC is right, you early filled a control.

Possibly it may depend on the state, in my state, it is not illegal to fill more than a 30 day supply of CIII-V, and I commonly fill 90 day supply's for C's for people because of the insurance benefits of it. Even if the RX were written as a 34 day supply (but it sounds like it was written as 1 - 1 & 1/2 tablets QHS making it a 22 day supply), but it's not illegal in my state to fill a 34 day supply of a C, and I'm guessing that is true in many other states as well.

What insurance pays has nothing to do with what you can legally dispense to a patient. If your PIC is not comfortable dispensing that dosage based on FDA guidelines, that is a completely different issue than not dispensing it because "ins doesn't pay for it."

 

[ResCon]

Possibly it may depend on the state, in my state, it is not illegal to fill more than a 30 day supply of CIII-V, and I commonly fill 90 day supply's for C's for people because of the insurance benefits of it. Even if the RX were written as a 34 day supply (but it sounds like it was written as 1 - 1 & 1/2 tablets QHS making it a 22 day supply), but it's not illegal in my state to fill a 34 day supply of a C, and I'm guessing that is true in many other states as well.

What insurance pays has nothing to do with what you can legally dispense to a patient. If your PIC is not comfortable dispensing that dosage based on FDA guidelines, that is a completely different issue than not dispensing it because "ins doesn't pay for it."

I think the PIC is simply using insurance company rules as a reflexive guide to diversion control, which isn't the smartest idea, IMO.

Anyway, patient picked up yesterday and had some words with the PIC. I actually agree with the patient, which of course I can't say in front of him.

Seems pretty insane to me though, almost unethical to refuse dispensing the quantity that was prescribed for the patient purely on the (stated) basis of insurance coverage.

 

[chuckle beast]

30 thru ins, 4 cash, then move on to more important things.

 

[Lnsean]

So, patient comes in with a script for Zolpidem w/ a written qty of 34 for 30 days. Sig states that patient can occasionally take a half tab. However, insurance will only cover 30 every month. I figure, okay, let's let the patient just pay cash for the extra 4, and we're good. To my surprise the PIC had a huge problem with this, saying that we can only dispense whatever insurance covers for controlled substances.

My problem is: wouldn't this be contrary to what the doc intended on the script? We're basically deciding what dose the patient is going to get, regardless of what the doc has indicated. What is insurance offered no coverage? Would we dispense nothing? Assuming patient is willing, why couldn't we just charge cash for the extra 4?

Have any of you all ever encountered such a policy WRT controlled substances and insurance quantity limits? (this is WAG, btw). When patient comes in, I'm trying to think of a way to explain it without it sounding like total nonsense.

Print screen this thread and show him what a ******* he is. They let anyone become PIC these days. I work for WAGS too...and there is no rule like that. You don't need his permission to fill that. You can just fill the 30 through insurance...have the patient pay out of pocket for the last 4 if they desire...he shouldn't have any say in what you can and cannot fill if it's legal. If he doesn't want to fill it...then you can fill it.

 

[Wheresmyaricept]

Print screen this thread and show him what a ******* he is. They let anyone become PIC these days. I work for WAGS too...and there is no rule like that. You don't need his permission to fill that. You can just fill the 30 through insurance...have the patient pay out of pocket for the last 4 if they desire...he shouldn't have any say in what you can and cannot fill if it's legal. If he doesn't want to fill it...then you can fill it.

Obviously you don't listen to the GFD rules. Paying cash for ANY controls is against company policy now. Anyone that allows this to happen will be subject to disciplinary actions.

 

[Ackj]

Obviously you don't listen to the GFD rules. Paying cash for ANY controls is against company policy now. Anyone that allows this to happen will be subject to disciplinary actions.

You have to be kidding. Patients without insurance won't get their meds?

 

[owlegrad]

Obviously you don't listen to the GFD rules. Paying cash for ANY controls is against company policy now. Anyone that allows this to happen will be subject to disciplinary actions.

When did that happen?!

 

[genesis09]

Walgreen's GFD policies do not stop people from paying cash or with discount cards. They just recommend a closer look at the prescription. My market got into trouble because we tried to ban the use of discount cards for controls.

 

[Lnsean]

Obviously you don't listen to the GFD rules. Paying cash for ANY controls is against company policy now. Anyone that allows this to happen will be subject to disciplinary actions.

I hope you are not working as a pharmacist. Please print out the policy and show me where it says pt cannot pay cash for it. It just warrants extra caution and attention. What if there is a patient who does not have insurance and legitimately needs it? I find it appalling that there are pharmacists out there who believes like you do without any application of common sense whatsoever...and on top of it...it's not even Walgreen's company policy. I think you just blindly followed what your PIC does because he's afraid to fill any narcotics for cash. Please actually read what the GFD says before making such a stupid comment.

source: I work for walgreens and I actually read all pages of the policy...i didn't pretend to read and go online and try to sound like a smartass with false information

 

[lorain]

zolpidem is only indicated for short term tx of insomnia....this drug is mis prescribed so much its not even funny

 

[joetrisman]

Obviously you don't listen to the GFD rules. Paying cash for ANY controls is against company policy now. Anyone that allows this to happen will be subject to disciplinary actions.

I hope you are not working as a pharmacist. Please print out the policy and show me where it says pt cannot pay cash for it. It just warrants extra caution and attention. What if there is a patient who does not have insurance and legitimately needs it? I find it appalling that there are pharmacists out there who believes like you do without any application of common sense whatsoever...and on top of it...it's not even Walgreen's company policy. I think you just blindly followed what your PIC does because he's afraid to fill any narcotics for cash. Please actually read what the GFD says before making such a stupid comment.

source: I work for walgreens and I actually read all pages of the policy...i didn't pretend to read and go online and try to sound like a smartass with false information

Not trying to take sides here, but fwiw, I'm at wags and have heard the same about it being against policy to do starting within the last year or so. However, I've never actually read the policy, im an intern that only works once a week so I rarely cross this situation, and it wouldn't be the first time a district manager has created a "company policy" that wasn't really true.

I feel the same way about this as I do about our new policy of not filling maintenance narcs without ICD9 codes from docs

 

[All4MyDaughter]

Not trying to take sides here, but fwiw, I'm at wags and have heard the same about it being against policy to do starting within the last year or so. However, I've never actually read the policy, im an intern that only works once a week so I rarely cross this situation, and it wouldn't be the first time a district manager has created a "company policy" that wasn't really true.

I feel the same way about this as I do about our new policy of not filling maintenance narcs without ICD9 codes from docs

That new policy sucks. All of the high maintenance patients from a certain local MD are transferring to our store. TAKE THEM BACK!

 

[Lnsean]

Not trying to take sides here, but fwiw, I'm at wags and have heard the same about it being against policy to do starting within the last year or so. However, I've never actually read the policy, im an intern that only works once a week so I rarely cross this situation, and it wouldn't be the first time a district manager has created a "company policy" that wasn't really true.

I feel the same way about this as I do about our new policy of not filling maintenance narcs without ICD9 codes from docs

The GFD policy does not forbid patients from paying out of pocket. The national GFD with walgreens is targeted against CII NARCOTICS, specifically oxycodones (not combo), hydromorphone, and methadone...however certain stores have included percocet 10/325 and oxycontins. Obviously, always do your due diligence when filling these medications, but please do not spread the mentality that you should never fill any controls for cash. That is nowhere in the policy. I don't even think that is legal. It is also against regulation to tell patients that you don't have them in stock when in fact you do just to get them to go away (Rite Aid and CVS are notorious for doing this).

I'm willing to bet my job that your district has no such policy as forbiding pt to pay cash for narcotics...and if your DM made up that policy...he should be really worried for his job right now.

Also you don't specifically need ICD9 codes...it just so happen that when you call...the office assistant will only see ICD9s in the pt's profile and thats all they give.

 

[gtpederson]

Obviously you don't listen to the GFD rules. Paying cash for ANY controls is against company policy now. Anyone that allows this to happen will be subject to disciplinary actions.

Maybe for missing out on signing them up for the Prescription Savings Club!