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Question about refills

Discussion in 'Pharmacy' started by Josuke(8), Aug 7, 2015.

  1. Josuke(8)

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    Okay, I'm studying for my boards and I had a question on refills.

    Legally (not best practice or insurance, but just legally) in the state of Maryland, if a patient had 5 refills on a 30 day supply of Lipitor, could he get all of them at once if he paid cash? What if it was Alprazolam?

    I feel like if it's a non CDS drug then their's no law preventing it, and the only thing making it illegal if it's a C3-5 would be the fact that there is a high potential for abuse so it wouldn't be legal to do so in that situation.
     
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  3. dblock05

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    No what is preventing it on Alprazolam is that the doctor wrote for #30 at one time with 5 refills. You do not get to say that he should get all of it at once.
     
  4. BidingMyTime

    BidingMyTime Lost Shaker Of Salt
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    Good question, but I don't know the answer for Maryland. In IL, both scenarios are explicitly legal, the law specifically states that a pharmacy can dispense all refills at the same time if the patient wants, including for controlled prescriptions. If the doctor doesn't like this, s/he must specifically writes something like "each refill must be 30 days apart" on the RX.
     
  5. Sine Cura

    Sine Cura 10 seconds or less
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    The fact that some states specifically address this issue indicates that for many states it is not explicitly permitted. In general you are supposed to dispense the quantity that is on the script, which is a basic requirement.

    For example, California has something on the books about this: http://codes.lp.findlaw.com/cacode/BPC/1/d2/9/3/s4064.5

    That there might be no law prohibiting it does not mean that there is an implicit right to do it (you are supposed to dispense based on how the prescription is written). For example most states do not have a law saying you can transfer a prescription that has not been previously dispensed by the transferring (origin) pharmacy, but the laws imply that the prescription should have been dispensed previously (by specifying need to transmit original date of fill). Massachusetts for example specifically has a policy for transferring Schedule VI scripts (for prescription-only drugs that are not federally controlled) not previously dispensed: http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/dhpl/pharmacy/pharmacy-regs/policies/public-health-regulations-pharmacy-2010-01.html
     
    #4 Sine Cura, Aug 8, 2015
    Last edited: Aug 9, 2015
  6. Son_Goku

    Son_Goku Probationary Status
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    Don't know why the law in MD is so flimsy, but Federal law in this case dictates the higher priority.
     
  7. SClENCE

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    In my state with the lipitor you can, with the alprazolam you cannot
     
  8. Old Timer

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    Really, so it's ok with Prozac or anything similar and then the patient OD's. It's not OK in PA. A prescription is a legal order for 30 at a time, so you give 30 at a time.
     
  9. owlegrad

    owlegrad Uncontrollable Sarcasm Machine
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    You can probably OD on 30 just as easily as you can with 90.

    To the OP, I have seen it done many times in FL but I don't think we have a statute that addresses the issue directly. I have worked with pharmacists that would and pharmacist that wouldn't combine refills. Personally I don't mind doing it and luckily the computer allows it.
     
    catalyzt likes this.
  10. Old Timer

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    Not really, the more you take usually the worse it is.
     
  11. SClENCE

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    The logic is that nobody is going to want to take 90 lipitor... while there are people who would want to take a huge amount of xanax. That's kind of the whole point of it being a controlled substance. Maybe there is some idiot out there that would try taking 90 lipitor but no law can protect you from your own stupidity.

    That being said, insurance obviously would reject it and if they are paying cash the pharmacist (if they are doing their job) should consult with the patient to be sure they are taking it as prescribed if they are picking it up significantly early/all at once
     
    #10 SClENCE, Aug 10, 2015
    Last edited: Aug 10, 2015
  12. BenJammin

    BenJammin No Apologies
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    In Texas you can only convert a 30 day supply into a 90 day supply as long as the patient is 18 years old, they consent, you notify the doctor via telephone or electronic means that you did it, the number of original refills doesn't exceed the change (30 DS with 2 refills = 90 DS with no refills), and the medication is not a psychotropic drug.
     
  13. wagrxm2000

    wagrxm2000 Do not respond to this
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    So they will just put it off for two months and take all 90 then. Ridiculous reasoning
     
  14. Old Timer

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    Really. While I'm sure it could happen that way it's rare. That's why many states don't permit and those that do, exempt pschoactive medications. It is real.
     
  15. Ackj

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    Probably over 99% of rx are for 30 or 90 days, but there are a few patients who ask for more. Usually the insurance will be the limiting factor, although if the patient wants to pay cash, they certainly can do it, especially if their doctor is on board with it. I have a husband and wife who regularly get 6 month supplies of simvastatin, lisinopril, hctz, omeprazole. They go to their 6 month checkup, and come in with Rx for #180 1qd and pay cash. I also had a guy who was going to some work assignment in Dubai or something like that and would be out of the country for like 6 months. We got an override in place with his insurance and they had us process his 30 day rxs 6 times in a row for him.

    I know the OP is asking about legal standing, and not insurance limits, but I really can't speak for Maryland. NY doesn't explicitly mention anything about limits on non-controls to the best of my knowledge.
     
  16. Ackj

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    Does PA really not allow 90 day supplies? Acetaminophen and aspirin are the most common intentional overdoses anyway, so I don't know if limiting patients to #30 on an rx is saving too many lives/livers.
     
  17. socalpharm86

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    I'm in California and readily convert eligible scripts to 90 days.
     
    #16 socalpharm86, Aug 10, 2015
    Last edited: Aug 10, 2015
  18. Old Timer

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    Sure they do. But if a doctor orders 30 at a time and you give 90, it's on you. People don't usually intentionally OD on ASA or APAP.
     
  19. zelman

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    It's not an insignificant portion of single-ingredient suicides...

    From: http://www.cdc.gov/ViolencePrevention/pdf/NVDRS_Data_Brief-a.pdf

    Over-the-counter drugs such as acetaminophen were the second leading substance type used in suicides. They represented 10% of suicides due to substance overdose (n=279).
     
  20. Old Timer

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    But the number of suicides due to OTC drugs is about 3% while 79% due to prescription drugs
     
  21. zelman

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    You're right that it isn't many (I don't see where you got 3%, though). In fact, it's probably a lower number than alcohol. But it's a large enough number that we might expect that people looking to commit suicide by medication would consider OTCs as a viable alternative when faced with the fact that their pharmacist won't combine refills.
     
  22. Old Timer

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    Because about 25% of suicides are from drugs and about 10% of them are from OTC drugs, so I rounded it up top 3%.
     
  23. Rockinacoustic

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    Are you asking if you can consolidate refills and dispense a prescription for #150 Lipitor, or allow the patient to pick up all 5 refills one after the other on the same day?
     
  24. Old Timer

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    They are asking if you get an RX for Lipitor 10 mg# 30 with 5 refills can you dispense 180 tablets as a single rx. In Pennsylvania, the answer is no. Your mileage may vary.
     
  25. Rockinacoustic

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    Sorry, math error- meant #180.

    I don't believe the statute says anything about refills beyond they can be dispensed if indicated by the presciber, and when emergency refills are appropriate. My interpretation of the MD law is you can't consolidate refills.
     
  26. NateRobinson

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    If its non controlled, I don't see why not. I had a patient who would go in a submarine for 8 months at a time. his doc would write for 90 with 11 refills of his BP, cholesterol, depression meds. I would dispense him 270 tablets cash, and just knock out the refills. There's no reason why we can't do that. He also had I think Omeprazole twice a day, so i'd give him 540 of that.

    There's a big difference between a guy who goes into a submarine for 8 months and wants Lisinopril and Bupropion VERSUS a guy who just wants 600 tablets of Clonazepam just because. Every case is different. Thats why you have to use your best judgment.

    Put it this way. If you go to court, would the judge understand? Make yourself a judge. If he asks why you gave a guy 540 capsules of omeprazole 20, and you say because hes under water for a year at a time, that makes sense. If he asks why you gave 150 tablets of Ambien to someone, and you say "because he asked for it", that's a whole different story.
     
  27. BidingMyTime

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    Illinois permits consolidation of refills of *all* drugs, there is no exemption for psychoactive drugs. Of course, its assumed that doctors understand the law, and they can prevent consolidation by explicating writing on the prescription something like "each refill must be 30 days apart" or by not giving any refills to begin with. Pharmacists, of course, can always use their judgement, and refuse consolidation. IE, I would most likely refuse the person who wants to pay cash for 6 months of Xanax at once, but have no problem with the person who wants to get 3 months of Xanax because they get an insurance break for 90 days. Given this, I'm surprised more states don't allow this (or that pharmacists like yourself would not want this.)
     
  28. trailerpark

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    Why don't the patients bring it up with the Dr so it can be written right on the rx.... I don't have extra time to deal with this nonsense.
    [​IMG]
     
  29. Old Timer

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    Didn't say I wasn't in favor of having the option. I just explained the historic reasoning and the Pennsylvania Law. It would save me a lot of time when plans require a 90 day supply and the RX is written for 30.
     
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