Pill count question from physician

[cbrons]

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I admit that I am embarrassed somewhat to ask this question, but:

For example, I wrote a prescription for Effexor XR today (the actual drug in this case is irrelevant, I run into this problem with a variety of other drugs that require a brief period of a lower dose).

I usually do 7-days of the 37.5mg capsules, then tell patient to take 2 of the capsules (for a total of 75mg) for the remaining 23-days of the 30-day prescription. This means I am writing a single prescription for 37.5mg capsules with a total count of 53.

I have been told by a pharmacist colleague that this is not the ideal way to write the prescription and that I should be writing 2 separate prescriptions, one for the 37.5mg for 7 day supply; and then a brand new one for a 30-day or 90-days of the 75mg capsules. For some reason doing it like this is less expensive for the patient.

I've also done it where I give 90 days of the 37.5mg and prescribe 173 capsules (7 days of one capsule, then 83 days of two capsules); I've been told this drives pharmacies crazy as they don't always have that many capsules on hand of the 37.5mg.

Is this true? How do I optimize my RXes to make it less of a hassle for the pharmacy and the patient?>

 

[CynicalIntern]

The pharmacist who told you that was dumb and didn't appreciate what you were doing.

If you can convince the patient to double up on the lower strength for the first month, that means you're essentially saving them a copay. If you write for a 7 day supply of Effexor XR 37.5, probably 85% of insurances are going to charge you the same copay as a 30 day supply - so you're essentially doubling their price by writing for both the 37.5 and the 75mg strengths.

I would keep doing what you're doing, but if you wanted to prevent any confusion (I know there are PBMs that exist that say max of 1 capsule per day even though it's only costing them an extra $2.45), you could put in your comments "may substitute 1 XR 75 for 2 XR 37.5 if cheaper for patient"

Honestly, the fact that you've calculated out 53 and 173 capsules means you're the ideal prescriber and shouldn't be embarrassed.

 

[RxPreceptor]

I don't see what's wrong with how you Rx'ed unless you are e-scribing & keep regenerating the Rx with the same outdated directions like I witness many (lazy) MDs do. Insurance is the usual obstacle as some will have a limit "1 capsule per day" when higher strengths exist due to costs (often many drugs will have the same cash price per capsule regardless of strength). Hard to make any absolute rules on this because insurance is often the high/almighty factor determining what is "right" for the patient (comes down to $$$ unfortunately...just to make both our jobs more tedious & stressful).

By no means something to be embarrassed to ask about

 

[CetiAlphaFive]

I admit that I am embarrassed somewhat to ask this question, but:

For example, I wrote a prescription for Effexor XR today (the actual drug in this case is irrelevant, I run into this problem with a variety of other drugs that require a brief period of a lower dose).

I usually do 7-days of the 37.5mg capsules, then tell patient to take 2 of the capsules (for a total of 75mg) for the remaining 23-days of the 30-day prescription. This means I am writing a single prescription for 37.5mg capsules with a total count of 53.

I have been told by a pharmacist colleague that this is not the ideal way to write the prescription and that I should be writing 2 separate prescriptions, one for the 37.5mg for 7 day supply; and then a brand new one for a 30-day or 90-days of the 75mg capsules. For some reason doing it like this is less expensive for the patient.

I've also done it where I give 90 days of the 37.5mg and prescribe 173 capsules (7 days of one capsule, then 83 days of two capsules); I've been told this drives pharmacies crazy as they don't always have that many capsules on hand of the 37.5mg.

Is this true? How do I optimize my RXes to make it less of a hassle for the pharmacy and the patient?>

I would love it if my physicians were this considerate and willing to put in that kind of effort.

 

[John Detter]

I usually do 7-days of the 37.5mg capsules, then tell patient to take 2 of the capsules (for a total of 75mg) for the remaining 23-days of the 30-day prescription. This means I am writing a single prescription for 37.5mg capsules with a total count of 53.

Keep doing this. My only suggestion is to do no refills on the initial script that includes the titration. Then write a separate script for 75 mg PO daily the following month. If you use an EMR to prescribe, make sure to avoid reordering that first script with the titration instructions.

 

[wagrxm2000]

A lot of insurances won't pay for 2 capsules per day when there's a higher strength.

Unlike others, I'd recommend against this or even better keep doing it but put a note saying may split script if required by insurance.

 

[ecrofom]

A lot of insurances won't pay for 2 capsules per day when there's a higher strength.

Unlike others, I'd recommend against this or even better keep doing it but put a note saying may split script if required by insurance.

This is the right answer

 

[CetiAlphaFive]

This is the right answer

Nah, it's the right answer for his patient population.

I can't simply say "most" insurance companies without qualifying it.

 

[BidingMyTime]

The real problem is, patients are going to get confused no matter what you do. You write for 2x37.5 mg, pt comes into the hospital where they are going to get 1x75mg, then when they are discharged, they are given a new RX for 1x75mg, but they don't read the directions so they keep taking 2 capsules, only now they are getting 150mg dose instead of 75mg dose. And then they end back up in the ER. Maybe not with Wellbutrin, but I've seen this scenario with other drugs (carvedilol and furosemide seem to be common ones.)

Ideally, don't write for the patient to take 2x anything, when there is a higher strength available, because at some point, the patient is likely to get the higher strength pill, but they will keep taking 2x of it.

 

[PharFromNormal]

I think for the initial prescription, the current approach is fantastic (provided it’s agreeable with any payer dynamics and nets out to the best cost position for the patient which can be extremely variable depending on many factors). The biggest thing that I pray you don’t do, which I doubt you do based on the care you are showing to come here and ask this question, is don’t put refills on the initial prescription and when a refill is requested, provide a new prescription with the maintenance dose and instructions.

 

[VA Hopeful Dr]

A lot of insurances won't pay for 2 capsules per day when there's a higher strength.

Unlike others, I'd recommend against this or even better keep doing it but put a note saying may split script if required by insurance.

So if we put a note saying you can make a second prescription if Insurance requires it, y'all can do that on your own authority?

 

[Slippers]

Doctors in my area are lazy AH. They just include the directions as you've stated, and write an Rx for Effexor 37.5 mg #60 and are done with it, insurance be damned. Oh, and they always put refills too.

The amount of thought and effort you are putting into this is commendable, I wish other MDs would put in half the effort that you do. Especially the ones that possibly need to look into getting hand surgery.

 

[CetiAlphaFive]

So if we put a note saying you can make a second prescription if Insurance requires it, y'all can do that on your own authority?

Yeah, I would.

 

[wagrxm2000]

So if we put a note saying you can make a second prescription if Insurance requires it, y'all can do that on your own authority?

If it's clearly documented on the script? Yes. I see it often with eye drops. They write for brand but say if too expensive, give the cheap stuff.

 

[radio frequency]

So if we put a note saying you can make a second prescription if Insurance requires it, y'all can do that on your own authority?

I absolutely do this all the time where I work now, whether a note exists or not. I know where I previously worked, I could have been reprimanded for doing this, so I was forced to call on all of these before and document, so a note would have saved us all time.