Retail pharmacy questions

[pharmraised]

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I am new to retail pharmacy and have some questions.

How do you deal with a situation where the md forgets to write out the quantity in letter and numbers for a CII prescription? Whats the best way of dealing with it?

If a customer is completely out of say, combivent or insulin, would you give them an emergency supply?

Whats the rule for calculating days supply of topicals? Inhaler meds? insulin?

 

[owlegrad]

I am new to retail pharmacy and have some questions.

How do you deal with a situation where the md forgets to write out the quantity in letter and numbers for a CII prescription? Whats the best way of dealing with it?

If a customer is completely out of say, combivent or insulin, would you give them an emergency supply?

Whats the rule for calculating days supply of topicals? Inhaler meds? insulin?

For the first one, pharmacists I work with will fill in the missing info.

No. Some insulin can be purchased without a prescription (check your state law I guess).

If you can calculated based on instructions, do that (number of actuations, number of units, etc), otherwise I use 30 days.

 

[PharmDstudent]

If you can calculated based on instructions, do that (number of actuations, number of units, etc), otherwise I use 30 days.

That's a good way to **** off a lot of patients, especially with topicals. Talk about having a "refill too soon" fight on your hands. So a 15gm tube of hydrocortisone or triamcinolone usually lasts 30 days? Ha! The day supply on a topical is up to the pharmacist's discretion... or at least that's what the insurance companies have told me.

 

[owlegrad]

That's a good way to **** off a lot of patients, especially with topicals. Talk about having a "refill too soon" fight on your hands. So a 15gm tube of hydrocortisone or triamcinolone usually lasts 30 days? Ha! The day supply on a topical is up to the pharmacist's discretion... or at least that's what the insurance companies have told me.

So what do you use?

 

[habeansha]

I am new to retail pharmacy and have some questions.

How do you deal with a situation where the md forgets to write out the quantity in letter and numbers for a CII prescription? Whats the best way of dealing with it?

If a customer is completely out of say, combivent or insulin, would you give them an emergency supply?

Whats the rule for calculating days supply of topicals? Inhaler meds? insulin?

1. have the pt take the script back to the MD, they should know how to write a script. also im pretty sure my state law only allows pharmacist to add the pts address to a C2 script

2. ummm, call the Dr and get a new script? i guess if they are closed I would give it to them and just bill it when i can get a script. also make sure they have been on it for a reasonable amt of time

3. topicals you judge by the area (ask pt where they are applying it), if their not around i usually go with 7 or 14 days depending on the size of the tube. inhalers and insulin are easy since its a set # of doses in the device/container and just go with that. i always wondered if waste ever matters, since with insulin pens they have to prime ~3 units each time they inject.

 

[PharmDstudent]

So what do you use?

It depends on the size of the area and the tube as well as the number of refills.

If it's a small tube for an older child or an adult with no refills, I'll use 7 days, and if it has refills, I'll use 5 days, eg triamcinolone. The number of refills can give you an idea of the length of therapy, which could mean more of it will need to be used (or refilled). If it's a small tube for an infant or a young child, regardless of refills, I'll use 7 days.

If it's a larger tube with no refills, then I'll use 10 days. If it has refills, then I'll use 7 days.

If it's an over-sized tube, like 80gm or 100gm, or a 1 pound jar, then I'll use 14 days regardless of refills. Common sense would tell you that a large tube should last a good while... but you really need to know the size of the area with burns, because if the patient runs out of treatment, they could be in for trouble. For example, once I dispensed a 1 pound jar of silver sulfadiazine with a 5 day supply, because the adult patient had to use it over a very large area. I even talked to the patient about the day supply to make sure that they would have enough until their next appointment.

If the patient has oral antibiotics with a topical antibiotic, then I'll use 7 days regardless of the size of the tube, eg mupirocin. The use of oral antibiotics should also help to reduce the area of the infection over time.

... since you asked! 😉

 

[All4MyDaughter]

No. Some insulin can be purchased without a prescription (check your state law I guess).

What insulins are available OTC? Are the OTC insulins therapeutically equivalent to RX insulins? I had a patient on Lantus (60 units SQ QHS) who was out of refills and out of insulin on Saturday. What OTC insulin would you have suggested he purchase and how would you tell him to use it?

 

[xiphoid2010]

Don't know about other states, but regular, NPH and combos of these don't need RX in Ohio. When converting NPH to lantus, the lantus dose = total daily NPH x0.8. But there is no way in hell I'm would recommend a retail patient to go from lantus to NPH. Pt very well might had lows on NPH that caused the switch to lantus. Don't risk your license like that.

 

[CellarDoor]

But don't we also have to consider risk of not helping the patient? (In terms of hyperosmolar states)

With NPH, I would definitely be worried about hypoglycemic events since the time-profile of NPH is not as smooth as lantus, so erring on the newbie conservative side I would think 20 units SQ before breakfast and 20 units SQ before dinner might be reasonable. Of course, check with patient about eating habits/daily schedule to make sure this would work for them.

I'm curious, what did you do for the patient in this situation?

 

[owlegrad]

I'm curious, what did you do for the patient in this situation?

Being the best pharmacist in the world, I bet she spotted him the Lantus.

 

[All4MyDaughter]

Don't know about other states, but regular, NPH and combos of these don't need RX in Ohio. When converting NPH to lantus, the lantus dose = total daily NPH x0.8. But there is no way in hell I'm would recommend a retail patient to go from lantus to NPH. Pt very well might had lows on NPH that caused the switch to lantus. Don't risk your license like that.

That's what I was driving at. OTC insulin (in most cases) is not an acceptable sub for RX insulin and I wouldn't be comfortable recommending it. I've NEVER sold insulin OTC.

But don't we also have to consider risk of not helping the patient? (In terms of hyperosmolar states)

With NPH, I would definitely be worried about hypoglycemic events since the time-profile of NPH is not as smooth as lantus, so erring on the newbie conservative side I would think 20 units SQ before breakfast and 20 units SQ before dinner might be reasonable. Of course, check with patient about eating habits/daily schedule to make sure this would work for them.

I'm curious, what did you do for the patient in this situation?

I gave him a vial of Lantus. He was known to my technicians and has consistently been filling the RX for months at our pharmacy. I noted his account and when his refill comes through (it probably did today), he'll just get 2 vials instead of his usual three.

 

[owlegrad]

I gave him a vial of Lantus.

Called it

 

[PharmDstudent]

That's what I was driving at. OTC insulin (in most cases) is not an acceptable sub for RX insulin and I wouldn't be comfortable recommending it. I've NEVER sold insulin OTC.

A couple of our patients buy it OTC.

 

[pezdispenser]

If a customer is completely out of say, combivent or insulin, would you give them an emergency supply?

Another option, if the main thing you are worried about is not getting a script so you basically gave away something for free, is you can explain to the patient that you need a script to claim money from their insurance, so in order to give them an emergency supply, they will have to pay the full cash price upfront, which you will refund to them once you receive the script.

 

[pezdispenser]

But there is no way in hell I'm would recommend a retail patient to go from lantus to NPH. Pt very well might had lows on NPH that caused the switch to lantus. Don't risk your license like that.

That's what I was driving at. OTC insulin (in most cases) is not an acceptable sub for RX insulin and I wouldn't be comfortable recommending it. I've NEVER sold insulin OTC.

To go off on a tangent, would anyone like to discuss prescriptive authority for pharmacists? Here we have a powerful 'drug', insulin regular and NPH, already available for purchase OTC without a prescription. But actually prescribing it would entail at least providing a dosage for the patient, yet a lot of us, including me, are not comfortable to do so. What would it take for you to be comfortable prescribing drugs?

 

[xiphoid2010]

What would it take for you to be comfortable prescribing drugs?

1 month of ambulatory/diabetes care at VA and you get pretty good at it. After 2 months it gets boring.

 

[All4MyDaughter]

To go off on a tangent, would anyone like to discuss prescriptive authority for pharmacists? Here we have a powerful 'drug', insulin regular and NPH, already available for purchase OTC without a prescription. But actually prescribing it would entail at least providing a dosage for the patient, yet a lot of us, including me, are not comfortable to do so. What would it take for you to be comfortable prescribing drugs?

I already RX drugs under collaborative relationships with providers at the coumadin clinic and diabetes clinic that are part of my residency. I'm comfortable doing it, but wouldn't do it in a retail pharmacy setting because of liability. Now, if I had better access to patient medical records, medical history, diagnostic tools, etc... that would be different.

1 month of ambulatory/diabetes care at VA and you get pretty good at it. After 2 months it gets boring.

I disagree. I think managing diabetes is interesting and challenging. But I'm an amb care person.

 

[Pharmpills]

1. have the pt take the script back to the MD, they should know how to write a script. also im pretty sure my state law only allows pharmacist to add the pts address to a C2 script

2. ummm, call the Dr and get a new script? i guess if they are closed I would give it to them and just bill it when i can get a script. also make sure they have been on it for a reasonable amt of time

3. topicals you judge by the area (ask pt where they are applying it), if their not around i usually go with 7 or 14 days depending on the size of the tube. inhalers and insulin are easy since its a set # of doses in the device/container and just go with that. i always wondered if waste ever matters, since with insulin pens they have to prime ~3 units each time they inject.

your number 1 cracks me up. They will eat u up alive and so will the Doctor . There is no need for a patient to drive back all the way to the hospital/clinic to get the doctor to simply write out the numbers. It can be written in but just make sure the pt got it before or an effort to contact the MD was made or you have their license info.

2. Giving a patient a box of insulin or expensive inhalers as an emergency supply will get you in trouble because what if the MD don't ever call it in then what? Patient can pay for certain insulins which are otc in FL. Not sure with other states. Someone had said if they are the same as RX and the answer is yes.

3. I think that's at the discretion of the pharmacist and can be complicated due to some insurance. Generally i think around a 15 days supply for a small to medium tube and a 30 days supply for larger tubes but this all depends on how often they use it and where. Also, keep in mind if refills were authorized with the rx bc billing a 30 days supply for small tube when someone has several refills will cause problems when they come to refill and rts pops up

 

[Farmercyst]

For topicals,if I don't have a patient to ask about surface area, I generally divide the size in grams by the frequency. Not because everyone automatically uses a gram per use, but it's easy math and I haven't had to fight insurance audits or refill too soon rejects using that rationale.

 

[owlegrad]

For topicals,if I don't have a patient to ask about surface area, I generally divide the size in grams by the frequency. Not because everyone automatically uses a gram per use, but it's easy math and I haven't had to fight insurance audits or refill too soon rejects using that rationale.

Oh I like this. 👍

 

[BidingMyTime]

Maybe I'm not reading it right, but I assumed that PharmDStudent was saying that if a pt is using an OTC insulin (ie Humulin/Novolin), and his prescription has run out of refills, then he'd just sell him the OTC insulin--not that he'd recommend a different insulin to a patient who was out of their prescription insulin.

I also have seen people buy OTC insulins without a prescription, because they were between doctors or couldn't afford to go to the doctor.

If a regular customer was out of refills and the dr couldn't be reached, I'd front them the prscription insulin or inhaler, as these are life-saving meds & if they are a regular customer, I know I will almost certainly get a renewal script from the doctor & that the customer will be back to pay the co-pay.

Topicals is always a guessing game...when in doubt, go with the shorter supply for the first fill. For refills, I go by how long it was between the original fill & the patient's request for a refill. In my experience, on a topical the chances of having to call the insurance to get a RTS override over a days supply, is much greater than getting audited over a days supply. The exception would be acne topicals--I generally go with 28 day supply for them. Of course, always document any additional information if you can.

Insulins & inhalers, use their dosing to figure the exact days supply.

With CII's, it depends on the state law. There are some states where pretty much nothing on the RX can be changed, other states are more lenient. My state currently allows the quantity to be added/written out, but at one time this was against the law.