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prescribing meds in tubes: do u need to lookup # of gm?

Discussion in 'General Residency Issues' started by 2007er, Mar 7, 2007.

  1. 2007er

    2007er Junior Member
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    So some meds that comes in tubes such as ointments, do u have to look up the # of grams for each of them or can u just write: "disp 1 tube" and the patient can choose what size they want to buy at pharmacy? will pharmacist call u if u leave the size empty?
     
  2. Winged Scapula

    Winged Scapula Cougariffic!
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    I've always just written "disp 1 tube" if I don't know the number of grams and to date, I've yet to have a pharmacist call me to clarify. Doesn't mean its correct, but most pharmacies probably carry standard sizes for its topical meds.
     
  3. Blue Dog

    Blue Dog Fides et ratio.
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    Cremes and gels are frequently (but not always) packaged in 15-gm increments (15, 30, 45, 60, etc.). Think S, M, L, XL. ;)

    If you're not sure, you can write "small tube," "large tube," etc. and let the pharmacist choose for you.
     
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  4. Winged Scapula

    Winged Scapula Cougariffic!
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    Well, you learn something new everyday. You'd think with all that anti-fungal cream in my medicine cabinet I would have figured it out by now! ;)
     
  5. Blue Dog

    Blue Dog Fides et ratio.
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    Ewww....! TMI, TMI! ;)
     
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  6. Bitsy3221

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    :laugh: :laugh: :laugh:

    Is "quantity sufficient" no longer applicable?
     
  7. Blue Dog

    Blue Dog Fides et ratio.
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    I only use "QS" when I'm too lazy to do the math to figure out how many mL of something to dispense. You have to give the pharmacist something to calculate, however...they're not going to be able to guess what size tube you were thinking of unless they're mind-readers. ;)
     
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  8. motmas

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  9. Samoa

    Physician Pharmacist 10+ Year Member

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    Please do not write prescriptions in "finger-tip units"!!!

    I mean, unless you want the pharmacist to call you. 15, 30, 45, 60, or 80 grams is standard, and not horribly difficult.

    If you have trouble remembering that, then just remember 30, 60 or 80 (yes, it should be 90 for simplicity, but it's not).
     
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  10. sdn1977

    sdn1977 Senior Member
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    I'm good with small tube, large tube, etc....I actually ask the pt what size of an area they are apply the product to which gives me an idea. I try to maximize the amount for the insurance copay without providing too much which might promote adverse effects (like using a steroid too long). So, the duration of application you want for them helps too.

    As Kent said, most are in 15G units except things like mupirocin oint - 22G (go figure - the cream is 30Gm!), Retin A Micro - 20Gm, Benzamycin & Benzaclin - 25 & 50Gm. Just write something & we'll come close without calling you.

    If you're prescribing something like Elimite - 1 tube is the dose - they use it all.

    If you write "use sparingly" & indicate something small - like 10G - I'll use the smallest available - like a 15G.

    If you write Kenalog in Orabase 30Gm - I disregard your quantity. Its only available in a 5Gm tube & is only applied to the lips, gums, etc...so that's what I give.

    Likewise...if you write erythromycin ophthalmic ointment & write for 30Gm - again I disregard & dispense the only available size 3.5gm.

    Please don't use "finger-tip units" - that will win you a call from me!:D
     
  11. Samoa

    Physician Pharmacist 10+ Year Member

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    100% correct as usual, but too complicated. As you say, most of the time you dispense the appropriate size, based on the clinical situation, without calling.

    I vote we just write small/medium/large and let you decide. I used to love doctors who did that, back when I was in retail.
     
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  12. OP
    OP
    2007er

    2007er Junior Member
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    is copay the same whether u prescribe small tube or large tube? If a small tube costs $80 and a large tube costs $160, for most standard prescription plans, what's the copay?
     
  13. Samoa

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    Usually it's same for both. Most copays are determined by the nature of the drug (i.e. brand vs. generic vs. nonformulary/nonpreferred brand), not by the amount prescribed. It's always 1 copay per 30-day supply.

    Unless you have crappy insurance: some plans make you pay a percentage, and others consider 28 days' worth to be a month supply. Still others will only let you get 15 days at a time, or will limit the total number of prescriptions you can get per month. Others (like my school's student insurance) have a really low cap on the total dollar amount they will cover. There seem to be an infinite number of ways in which insurance companies can avoid providing adequate coverage. And unfortunately in retail pharmacy we see them all.
     
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  14. sdn1977

    sdn1977 Senior Member
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    Well....kind of.....

    I do hate to belabor points - but these are prescribers & future prescribers so we need to be honest here.

    We are subject to audits constantly - in 2006, I had 4 audtis from 4 different insurance companies - about 100 pts each. Sounds like not so much - right? Except - I had to find each original rx, each documented refill (the pharmacist's notations of fill), each fill's receipt by the pt or pt's representative's signature....so accuracy is of primary importance. Each audit took me 6 hours to complete. If I could not document each item on the audit - the insurance company had the ability to nulify payments on ALL pts who were on the audit request. Sounds irrational? Yep!

    Take your TAC 0.1% cream - 30Gm - apply qd ud - no problem- I can put a 10, 15, 30 or whatever day supply on that I want to make it fit the insurance.

    But...if its now a psoriasis pt - if I'm going to be billing Dovonex 120Gm rather than 60Gm - I have to document on the rx the product will be applied to sufficient surface area that 120Gm will last only 1 month. Now, you might ask - so just do it - but now the insurance companies are requiring documentation from phsycian's offices that indeed 120Gm is just a 30 day supply (which implies a substantial body surface area involved). If & when the physician documents that - then the physician is subject to audit - many don't want that so are reluctant to provide that substiantion. Also, if the drug is not ordered on a monthly (or 60 day, 90 day, etc basis consistently & the physician documentation doesn't correspond), my claim will also get rejected. Likewise - some insurance companies will decide it doesn't matter how much is ordered - they will limit their payment to only a certain quantity per month - happens to Norvasc, paroxetine & ppi's all the time - if you want your pt to take it twice a day - since it is designed as a once a day dose, unless you get a prior auth - the pt pays for the second dose per day & the insurance pays for one dose per day. Even if you get a PA, they may still say they only will pay so much per month - I've got 2 thalidomid pts who fall in this category - the bill is $1980/mo yet the insurance will pay a max of $500/claim.

    In the case of eye drops, ear drops or inhalers - the droppers & delivery devices are calibrated & the sig must match the days supply. Just because you want to give 3 Patanol's for a 30 day supply doesn't mean it will happen because we know how many drops you prescribe & how long the bottle will last. Yep - waste & "dripping" are included, but 3ml (actually 2.5) of Xalatan lasts 1 month for normal dosing - anything extra might require a PA.

    So....you think you can get around it by giving a sig - use as directed. Aaaah - within the practice of pharmacy - that will automatically get a denial of payment. Which is why we need to get the exact sig & is why we want to get the dosage change correct when you tell the pt to take 1 more tablet or use once more per day. Use as directed doesn't fly anymore - it must match your last documented recommendation in your chart.

    Now...not all insurances only allow a 30 day supply. In fact, almost all Medicare Part D plans allow for a 90 day supply. Some private plans allow for 60-90 days - it depends on what the employer "buys" for it employees.

    As for copays - currently, they are "tiered". That means for any one drug class - lets say topical steroids, statins, antibiotics - there are some on generic forumlary (lovastatin, pravastatin), some brand formulary (lipitor) & some non-formulary (crestor). Each has its own co-payment structure. Again - this is not defined - it is determined by the plan & the plan is often determined by how much the employer wants to spend rather than the employee (if you're a student - you spend little - thus you get little).

    So - as Samoa said earlier - far too complicated. But, really rx insurance, reimbursement & coverage is complicated - for the pt & the prescriber. But - at this point in time, there is nothing we can do but deal with the system we have which is fractured at best. But - on the prescriber's end - you must be able to document that what you tell me is indeed correct because they can & do audit us both. Periodically, there are publications for those who are under investigation for Medicare/Medicaid fraud & if you got caught in one, you'll get caught in private insurance fraud as well. It definitely not worth it to me & I can't imagine its worth it to you either.
     
  15. Samoa

    Physician Pharmacist 10+ Year Member

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    Yeah, I forgot to mention that the amount dispensed per copay is determined by the instructions for use, or by actual usage, or by the amount you write for, whichever is less, within the maximum days' supply allowed by the specific insurance company.

    We're basically saying the same thing.
     
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  16. motmas

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    Oy...I should have added the note that FTU aren't something I would write for - it took me freaking for ever to figure it out, so I wouldn't drive someone else nuts with that one on a script...but I think it's a helpful guideline to help you figure out how much to write for.
     
  17. OP
    OP
    2007er

    2007er Junior Member
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    the finger tip unit is pretty neat...

    The general idea i picked up from it is that 1 g = 4 palm surfaces = 2 finger tips of ointment.

    If you had eczema that's the area of 4 palm surfaces,

    4 palms/day * 1g /4 palms * 30 days/mo = 30 g/mo if it's qd.

    If you had an area the size of 1 palm, and u use ointment bid,

    1 palm/day * 1 g/4 palm * 30 days/mo * 2 times/day = 15 g/mo bid.

    Brings back the days of general chemistry....
     
  18. tum

    tum don't call it a comeback
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    you're hardcore man
     
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  19. Tired

    Tired Fading away
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    Interesting. I had an ER rotation earlier in the year, and we got called at least a half-dozen times asking what size we wanted the patient to get.

    As if I know what a 30g vs 60g tube looks like . . .
     
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  20. Blue Dog

    Blue Dog Fides et ratio.
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    Here are some guidelines:

    Area treated
    Amount of one application in grams
    # of grams of agent needed in BID application for 1 week
    # of grams of agent needed for BID application for 1 month

    Hands, head, face, anogenital
    2 grams
    28 grams
    120 grams (4oz)

    One arm, anterior or posterior trunk
    3 grams
    42 grams
    180 grams (6oz)

    One leg
    4 grams
    56 grams
    240 grams (8oz)

    Entire body
    30-60 grams
    420-840 grams (14-28 oz)
    1.8-3.6 kilograms (60-120 oz, 3.75-7.5 lbs)

    Source: K. Ardnt (1995) Manual of Dermatologic Therapeutics (5th Ed) Boston: Little Brown
     
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  21. sdn1977

    sdn1977 Senior Member
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    Far, far too many choices!

    Prescribe 0.5 oz, 1oz, 2oz, 4oz, or 16oz.

    If you write TAC 0.1% 2gm
    Apply to face, hands and genital area bid x 1 wk

    Trust me - I'm dispensing 15Gm - there is no way I'm weighing out 2Gm of TAC & it would cost far, far more for me to do that than to dispense the smallest tube commercially available.

    Or.....even worse - you get a phone call:D ....
     
  22. Blue Dog

    Blue Dog Fides et ratio.
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    Most of us would round up to the nearest available size.
     
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  23. Winged Scapula

    Winged Scapula Cougariffic!
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    maybe it was the picture of me holding a knife and threatening them that resulted in me getting fewer phone calls!;)
     
  24. sdn1977

    sdn1977 Senior Member
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    :laugh: :laugh: :laugh: :laugh:

    You have NO idea how we picture you when you order crazy sizes, qtys, etc.....:p

    I'm looooooong past calling on this crazy stuff - unless you generate me an audit.

    I use my best judgement - so I'm all good with "1 tube" - I can do that:) .
     
  25. sdn1977

    sdn1977 Senior Member
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    Yeah, but I don't want you to give 2007er & that guy with the fingertip/palm sizes any crazy ideas:scared: .
     
  26. wrested

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    So I read the title of the thread and thought you were talking about prescribing meds to be administered via ET tube...

    "Do I need to look up # of grams?" ... Not really, just pick a random amount of drug X and dump away... :laugh:
     
  27. Adcadet

    Adcadet Long way from Gate 27
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    Same here. But I figured you just determine the volume. In gallons.
     
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