Standard size cough syrup bottle

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tkim

tkim

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Hi, when I'm prescribing cough syrup I always wonder what the 'standard' volume to prescribe - 4oz - 8? I'm trying to figure out how much is too much or too little. Thoughts?
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Hmmm. Four ounces sounds a little 'skimpy'. What I'm trying to figure out is the amount that will take care of the problem, without too much left over, but not short the patient and have them return for a refill. I mean, if I were the patient, I'd love for my doc to write for me a big 'ol bottle of Tussionex for my copay.
 
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Rx bottles come in the following sizes:*


  • 1 oz (6 teaspoonfuls)
  • 2 oz (12 teaspoonfuls)
  • 3 oz (18 teaspoonfuls)
  • 4 oz (24 teaspoonfuls)
  • 6 oz (36 teaspoonfuls)
  • 8 oz (48 teaspoonfuls)
  • 12 oz (72 teaspoonfuls)
  • 16 oz (96 teaspoonfuls)
* Not all stores carry all sizes.
** approx 30 cc per ounce

Based on how many doses (at 5cc) you wish to prescribe, you select the correct bottle size.

Tussionex at 5 cc bid x 6 days --- 60 cc or 2 oz should be sufficient with a refill added if needed....
 
That's a great response, which I've copied to my PDA notes.

I've always wondered - do pharmacies take a 'hit' when a script is for a larger-than-normal dispensed amount? Say I write for a 16oz of something for the same copay. The pharmacy will make less for that script than say - a 4oz script.
 
tkim said:
That's a great response, which I've copied to my PDA notes.

I've always wondered - do pharmacies take a 'hit' when a script is for a larger-than-normal dispensed amount? Say I write for a 16oz of something for the same copay. The pharmacy will make less for that script than say - a 4oz script.
Click to expand...

Not necessarily, it's something I wouldn't worry about if I were on the other end of the Rx pad. On most all prescriptions, the pharmacy will bill the insurance for the increased product. What the pt is charged is a function of their plan, and if they have flat co-pays, then the increased cost of product is borne by the insurance plan.

There might be a slight difference in profit margin, but it's something you need not worry about it. What you may need to think of is whether a plan will cover the given drug at the given dosage/duration. If you give a pt 10mL TID for drug X qty: 120mL, this will technically be a 4 day supply. An insurance plan may reject it for duration and only cover 5mL TID...what the pharmacy would probably do is just adjust the days supply submitted to 8 and be done with it. Your pt won't be able to get a refill on day 5 (because insurance will say, "Hey, they're not supposed to be done with it"), but if it's a one time deal for, say, a cough...it's not going to be an issue. It'll be an issue if this is a maintenance med. In that case, you'll probably get a request for Prior Auth from the pharmacy.
 
tkim said:
That's a great response, which I've copied to my PDA notes.

I've always wondered - do pharmacies take a 'hit' when a script is for a larger-than-normal dispensed amount? Say I write for a 16oz of something for the same copay. The pharmacy will make less for that script than say - a 4oz script.
Click to expand...

No but they might look upon the script as less than as we say "good".

Who needs 96 doses of cough medication?

You should also familiarize yourself with maximum dosages of medications you are going to prescribe and not wing it.

Tussionex: 10 cc per day.
Promethazine Syrup 30 cc per day.
Promethazine VC Syrup 30 cc per day.
Promethazine w/codeine 30 cc per day.
Promethazine VC with codeine 30 cc per day.
Promethazine w/DM) 30 cc per day.
Robitussin AC (60cc per day), etc....
Hycodan Syrup 30 cc per day.
 
No VC anymore Mr. Oldie Pants. :smuggrin:



:p
 
Pharmacies will have their own computer programs to electronically bill the insurance companies. If you're super curious about how much the pharmacy is getting paid, you can usually look it up in the computer or in some pharmacies, it is printed on their labels (of course that part of the label is never given to the patients). What you're looking for is the cost of medication, the amount paid by the insurance, and the copay price.

Like confettiflyer mentioned, it's not necessary to get down to the details or worry too much about it. Perhaps, if you're a District Manager or Supervisor, this may be relevant if the issue is cutting profits substantially. In that case, this would be a systematic billing issue that can be fixed by the upper pharmacy management.

Most of us know insurance companies frequently change how they bill medications. In terms of cough medication, I don't recall frequently billing cough medications as a maintenance med so stretching the days supply is okay. That's just my experience.

Stretching the day supplies too much and/or too often may lead to problems later. Doing so may result in potential troubles when the pharmacy is being audited.


confettiflyer said:
Not necessarily, it's something I wouldn't worry about if I were on the other end of the Rx pad. On most all prescriptions, the pharmacy will bill the insurance for the increased product. What the pt is charged is a function of their plan, and if they have flat co-pays, then the increased cost of product is borne by the insurance plan.

There might be a slight difference in profit margin, but it's something you need not worry about it. What you may need to think of is whether a plan will cover the given drug at the given dosage/duration. If you give a pt 10mL TID for drug X qty: 120mL, this will technically be a 4 day supply. An insurance plan may reject it for duration and only cover 5mL TID...what the pharmacy would probably do is just adjust the days supply submitted to 8 and be done with it. Your pt won't be able to get a refill on day 5 (because insurance will say, "Hey, they're not supposed to be done with it"), but if it's a one time deal for, say, a cough...it's not going to be an issue. It'll be an issue if this is a maintenance med. In that case, you'll probably get a request for Prior Auth from the pharmacy.
Click to expand...
 
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Old Timer said:
No but they might look upon the script as less than as we say "good".

Who needs 96 doses of cough medication?

You should also familiarize yourself with maximum dosages of medications you are going to prescribe and not wing it.
Click to expand...

I'm not trying to wing it, I'm trying to figure out a reasonable length of treatment for something which can be variable such as cough. It has nothing to do with maximum dosage, per se, but number of dosages. Thanks for the info - the snarkiness I could have done without, however.

But the different volumes per dosage certainly helps in figuring out the total volume to write for. Thanks.
 
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tkim said:
I'm not trying to wing it, I'm trying to figure out a reasonable length of treatment for something which can be variable such as cough. It has nothing to do with maximum dosage, per se, but number of dosages. Thanks for the info - the snarkiness I could have done without, however.

But the different volumes per dosage certainly helps in figuring out the total volume to write for. Thanks.
Click to expand...

It is not snarkiness. It's giving you information you need to prevent being hassled by pharmacists calling to verify the validity of your order and delaying your patient from getting the medication. Write some scripts for 16oz of Phenergan w/codeine or 8 oz of Tussionex and see how fast they bounce back at you. The words you are looking for are:

Thank you for the information.....
 
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tkim said:
Hi, when I'm prescribing cough syrup I always wonder what the 'standard' volume to prescribe - 4oz - 8? I'm trying to figure out how much is too much or too little. Thoughts?
Click to expand...


For this quesiton, you could not have gotten a much better response than what Oldtimer provided. He's old and senile but he's pretty sharp. If your question involves the clinical aspect of "cough" then you should refer to ACCP Guideline on Treatment of coughs.

How long to treat a cough and how much cough syrup to provide depend on the underlying cause of cough such as simple cold, flu, ACEI induced, or asthma like irritability. Once you've diagnosed the underlying cause, then you can determine the length of tx and the size of the bottle.
 
Good advice from Old Timer. I usually go with this for prometh cough syrups: (just a different way of seeing it) Think about how many days' worth of cough syrup you think they'll need, and prescribe that in ounces. For example, if you think their cough will be gone in 3 or 4 days, just give them 4 ounces to get by. Or if it's a bad case of bronchitis and you think they'll be hacking up a lung for a week, give them 8 ounces. Just try to avoid prescribing weird numbers (e.g. 7 ounces) because rx liquid bottles come in the sizes that Old Timer listed above, so it's much easier for us to dispense if you write for nice round quantities!
 
Old Timer said:
It is not snarkiness. It's giving you information you need to prevent being hassled by pharmacists calling to verify the validity of your order and delaying your patient from getting the medication. Write some scripts for 16oz of Phenergan w/codeine or 8 oz of Tussionex and see how fast they bounce back at you. The words you are looking for are:

Thank you for the information.....
Click to expand...

Thank you for the information.
 
Old Timer said:
Of Tussionex??????
Click to expand...
Why not? That would be enough for a cough that won't go away, say 18 days. I just wouldn't give the script refills unless they still had the cough after 3 weeks.

The cough would have to be bad enough to require Tussionex, right? So what's wrong with 18 days to cover for a cough that won't go away?

Four ounces is pretty whimpy for most cough medicines, in general, in my opinion. Besides... what doctor's office wants to be bothered with cough medicine refills after the office visit? Just sayin'...
 
What amazes me is that nobody has told him the deal.

Fella, there are about 2 bazillion different prescription cough/cold remedies that have no common generic. A bunch of proprietary bull**** flooding the market. No matter what you do, there is a decent chance someone will call you if you go with a weird brand name drug. Keep it simple. With cough syrups....Phenergan with codeine...Tussionex...Hycodan...Lortab Elixer...Tussin AC. Just use those. Writing for anything else is asking to be bugged a few hours later. That cough medicine the hot little drug rep in the skirt told you about? We probably dont have it. Hell, we've probably never heard of it.
 
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WVUPharm2007 said:
That cough medicine the hot little drug rep in the skirt told you about? We probably dont have it. Hell, we've probably never heard of it.
Click to expand...

We probably heard of it because that that hot little rep in the short skirt was in the store 5 minutes after the doctor's office....
 
Old Timer said:
Well Ms. Smartie Pants I see that Avtavis still has it listed on their web-site, both plain and with codeine. :smuggrin:
Click to expand...
Correct me if I'm wrong, but weren't the cough medicines with VC pulled because they weren't FDA-approved? So... How is Actavis getting away with a VC product? Did they actually go through the FDA approval process? Or are they getting away with their product some other way?
 
Qualitest also has Phenergan VC with and without Codeine. It's available through Mckesson.
 
PharmDstudent said:
Correct me if I'm wrong, but weren't the cough medicines with VC pulled because they weren't FDA-approved? So... How is Actavis getting away with a VC product? Did they actually go through the FDA approval process? Or are they getting away with their product some other way?
Click to expand...


I believe Phenergan VC was originally approved by the FDA in the 50's. That's almost as old as Old Timer... :smuggrin:

And since then, it's gone through numerous label changes.
 
PharmDstudent said:
Correct me if I'm wrong, but weren't the cough medicines with VC pulled because they weren't FDA-approved? So... How is Actavis getting away with a VC product? Did they actually go through the FDA approval process? Or are they getting away with their product some other way?
Click to expand...

There is nothing called VC, my youngin... The VC stands for VasoConstrictor.

The ingredient in question is phenylephrine.......
 
ItsOverZyvox said:
Qualitest also has Phenergan VC with and without Codeine. It's available through Mckesson.
Click to expand...
I didn't ask you.
ItsOverZyvox said:
I believe Phenergan VC was originally approved by the FDA in the 50's. That's almost as old as Old Timer... :smuggrin:

And since then, it's gone through numerous label changes.
Click to expand...
Last verse, same as the first, i.e. I didn't ask you. Now go be annoying and egocentric to someone else.
Old Timer said:
There is nothing called VC, my youngin... The VC stands for VasoConstrictor.

The ingredient in question is phenylephrine.......
Click to expand...
Duh! I know what the active ingredient is, Mr. Snarky. The question is: WHY DID THEY PULL SO MUCH OF IT OFF THE MARKET? We can't even dispense a Prometh. with VC where I work/have worked, and I haven't seen it dispensed since all of it was pulled/discontinued a few years ago.
 
Promethazine VC and Promethazine VC w/Codeine were NOT removed from the market. There may have been certain manufacturers that were recalled due to quality reasons, but there is no FDA position that I am aware of that has forced a withdrawl from the market. Noth Actavis (formerly Barre Labs), the largest maker of liquid medication in the world and Qualitest still offer the product for sale.

As to why your store does not carry it, I do not know the reason. Sales are diminishing because it is ineffective.

And as for being snarky, It was not I that said
PharmDstudent said:
Correct me if I'm wrong, but weren't the cough medicines with VC pulled because they weren't FDA-approved?
Click to expand...
 
Old Timer said:
Promethazine VC and Promethazine VC w/Codeine were NOT removed from the market. There may have been certain manufacturers that were recalled due to quality reasons, but there is no FDA position that I am aware of that has forced a withdrawl from the market. Noth Actavis (formerly Barre Labs), the largest maker of liquid medication in the world and Qualitest still offer the product for sale.

As to why your store does not carry it, I do not know the reason. Sales are diminishing because it is ineffective.
Click to expand...
Thanks. There must have been some deeply ingrained folklore around here about syrups with VC, because every pharmacist that I know will say that "they don't make it anymore" or "it was pulled off the market" whenever someone brings in a script for it.

Old Timer said:
And as for being snarky, It was not I that said
Click to expand...
??? I knew what the drugs were (and didn't need the spiel that bordered on condescending), it's just that I didn't understand why y'all dispense Prometh with VC up there, but we don't dispense it down here. It's been gone for a long time, you know.
 
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Old Timer said:
Promethazine VC and Promethazine VC w/Codeine were NOT removed from the market.

Sales are diminishing because it is ineffective.
Click to expand...

Remember when Phenylpropanolamine (PPA) was taken off the market around 2001? I bet people associate phenylephrine with PPA.
 
WVUPharm2007 said:
That cough medicine the hot little drug rep in the skirt told you about?
Click to expand...

I'm seeing less and less of them. Instead, I'm seeing more seasoned and older reps who's been doing it for years. I'm not sure why.
 
ItsOverZyvox said:
Remember when Phenylpropanolamine (PPA) was taken off the market around 2001? I bet people associate phenylephrine with PPA.
Click to expand...
Nah. Some brands of Promethazine w/ codeine VC really were d/c'd a few years ago. I was also told it was no longer available at my store at the time. It's more likely that some suppliers just didn't stock the brands remaining on the market so we assumed it wasn't available anywhere anymore.
 
tkim said:
Hi, when I'm prescribing cough syrup I always wonder what the 'standard' volume to prescribe - 4oz - 8? I'm trying to figure out how much is too much or too little. Thoughts?
Click to expand...
Can I schedu an appointment?
 
I like it when they calculate the dose based on weight and it says "Take 8.5657 ml twice daily"
 
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Ackj said:
6 years too late. No longer accepting new patients.


And you can't even throw a refill on Tussionex anymore. How times have changed...
Click to expand...
Why can't you?
 
Every pharmacy has Tussionex it tastes so good.
 
I don't remember having any liquids in the hydrocodone safe but I could be wrong.
 
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