Type of changes a pharmacist can do without contacting prescibers

Feb 24, 2013
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I was wondering what type of changes a pharmacist can do on non-controlled rx without the need to contact the prescribers first. For example, prescriber wrote 29g needles for insulin pens but it's not available. Can a pharmacist switch it to 30g or 31g without needing to confirm with them?
 
Jun 15, 2011
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Unless you have a medical protocol signed off by the doctor allowing you to substitute drugs or change things, then pretty much nothing. Unless you're one of those cool states that can convert it to a 90 day supply. My state isn't that cool.


Then again if it's something stupid like changing the gauge for insulin pen needles, what's stopping you from just changing it because 99.9999% of doctors would be like "why are you calling just change it".
 
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msweph

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I can't imagine having to call a doctor to change a tablet size of a statin, etc
 
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BenJammin

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In Texas we're authorized to change dosage form as long as they're equivalent. Amoxicillin tablets to capsules to suspension to whatever. That sort of thing. Although I do wonder the legality of a doctor writing for albuterol HFA and just putting a brand name in its place.
 

BidingMyTime

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I can't imagine having to call a doctor to change a tablet size of a statin, etc
Do you mean substituting 2-20mg tablets for 1-40mg tablet (or something like that?) It may depend on your state, that kind of substituting is exceptable in IL (unfortunately, we aren't as cool as TX and can't change dosage forms)
 

msweph

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Do you mean substituting 2-20mg tablets for 1-40mg tablet (or something like that?) It may depend on your state, that kind of substituting is exceptable in IL (unfortunately, we aren't as cool as TX and can't change dosage forms)
More like 1/2 of a 40 mg d/t insurance reasons
 

stoichiometrist

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At the hospital where I did my IPPE, the pharmacists made renal dosing adjustments without contacting the prescriber, according to protocol.
 

zelman

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At the hospital where I did my IPPE, the pharmacists made renal dosing adjustments without contacting the prescriber, according to protocol.
Laws do not apply to hospitals' internal operations as far as I can tell.
 

maria1oh

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Also heard hospital pharmacists can switch a patients PPI or statin to whatever their hospital formulary is. Pantoprazole was the only PPI available at the hospital I rotated at.
 

gwarm01

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At the hospital where I did my IPPE, the pharmacists made renal dosing adjustments without contacting the prescriber, according to protocol.
We do a lot of stuff like that too. We order levels and change dosing/intervals on vanco and aminoglycosides
Also heard hospital pharmacists can switch a patients PPI or statin to whatever their hospital formulary is. Pantoprazole was the only PPI available at the hospital I rotated at.
It probably depends on the hospital, but things like this are pretty common. Protocols are developed and the formulary decided on by the P&T committee. I'm not sure how it is presented from the physician's standpoint, but it seems like there is an understanding that if you practice at institution A, you must abide by the rules and regulations of the institution. I think it makes it easier on everyone to sort of streamline the process like that. Besides, anytime we need to bend the rules for a valid medical reason most of us are willing to make it work.
 
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bobisnew

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I do the best and most efficient thing for the patient......Annotate "MD OK" and write what you feel is correct and benefits patient. Done!
 

marscole

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For example, insulin pen needles:

The script was written in 32G x 6 mm

But, only 31G x 4 mm and 31G x 8 mm available in the store. Should you stick with either one of them?
Or you tell the pt "Unfortunately, we don't have the written in stock. We will order for you, and will be available after xyz time. Is that okay for you?"
 

zelman

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For example, insulin pen needles:

The script was written in 32G x 6 mm

But, only 31G x 4 mm and 31G x 8 mm available in the store. Should you stick with either one of them?
Or you tell the pt "Unfortunately, we don't have the written in stock. We will order for you, and will be available after xyz time. Is that okay for you?"
In reality, you give what you have. From a legal perspective, you cannot do so. You must turn away the prescription or order the product.
 

Gunter

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Sorry to revive an old thread, but you can change the dose of the medication as long as they are AB rated in the orange book correct?
ex: doctor wrote for crestor 10mg which isn't cover on the pt's insurance but 5mg is cover, so you switched it to 2 of the 5mg to make 10mg.
 

zelman

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Sorry to revive an old thread, but you can change the dose of the medication as long as they are AB rated in the orange book correct?
ex: doctor wrote for crestor 10mg which isn't cover on the pt's insurance but 5mg is cover, so you switched it to 2 of the 5mg to make 10mg.
Not in any state where I’m licensed. And your example isn’t explicitly AB rated. Taking 3 tablets of 30mg Procardia XL gives different blood levels from taking one 90mg Procardia XL.
 
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Sorry to revive an old thread, but you can change the dose of the medication as long as they are AB rated in the orange book correct?
ex: doctor wrote for crestor 10mg which isn't cover on the pt's insurance but 5mg is cover, so you switched it to 2 of the 5mg to make 10mg.
It depends on some specifics. Where you work, what your state regs say. For retail in general:

If the rx is written crestor 10 mg hs 30 days supply that could be interpreted as just give crestor 10mg which could be 5's or 1/2 a 20. But if its written for crestor 10 #30 that means you have to give 10mg tablets.

I had a new grad pharmacy manager and tech make wholesale changes to ativan rxs (splitting a higher strength in half) because the desired strength was on a backorder. They did this by themselves without consulting the mds or counseling patients. They did this one refill rxs. Then the phone calls started coming in and people had continued to take a whole tablet but now they were taking too much.

Follow you states law and use good judgement.
 

giga

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In regards to needles/syringes, if the patient is willing to pay out of pocket, technically you can dispense them whatever needles you want without needing a prescription at all (in states where pharmacists are allowed to sell needles without a prescription, which is the case in most states). But if you're trying to run it through insurance, then my guess is that you potentially risk committing fraud if you don't document that the MD OKed the prescription change.
 

zelman

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In regards to needles/syringes, if the patient is willing to pay out of pocket, technically you can dispense them whatever needles you want without needing a prescription at all (in states where pharmacists are allowed to sell needles without a prescription, which is the case in most states). But if you're trying to run it through insurance, then my guess is that you potentially risk committing fraud if you don't document that the MD OKed the prescription change.
Only insulin syringes. Tuberculin syringe boxes say they are only to be sold with a prescription/order.
 
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Sine Cura

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Anything not ingested and not expensive I do not care about contacting anyone.

Here's another example I bet most pharmacists do not validate. Any Rx specifying "1 inhaler," or even better "1 spray" of pretty much any inhaler is an ambiguous order. Does anyone actually seek clarification on this?
 
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giga

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Only insulin syringes. Tuberculin syringe boxes say they are only to be sold with a prescription/order.
Definitely not just insulin syringes. You can sell pretty much any standard needle/syringe, including for IM injection (with the caveat that different states may have different restrictions on what a pharmacist can sell without a prescription). I don't specifically have experience selling tuberculin syringes, but a quick google search shows that you can buy them online without a prescription, and I don't see the "Rx only" marking on the boxes. There might be some specialty needles/syringes that are Rx only, but for the most part, there are a variety of syringe sizes and needle gauges and lengths that are available without prescription.
 
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zelman

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Definitely not just insulin syringes. You can sell pretty much any standard needle/syringe, including for IM injection (with the caveat that different states may have different restrictions on what a pharmacist can sell without a prescription). I don't specifically have experience selling tuberculin syringes, but a quick google search shows that you can buy them online without a prescription, and I don't see the "Rx only" marking on the boxes. There might be some specialty needles/syringes that are Rx only, but for the most part, there are a variety of syringe sizes and needle gauges and lengths that are available without prescription.
You sure?
 

giga

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Looking at the FDA's medical device database, it lists "No" for both "Prescription Use" and "Over The Counter": AccessGUDID - DEVICE: 1ml Tuberculin Suresafe Syringe (05391530750219)

The definition for Prescription Use and Over the Counter are as follows:
Prescription Use (Rx): Indicates that the device requires a prescription to use.
Over the Counter (OTC): Indicates that the device does not require a prescription to use and can be purchased over the counter (OTC).
(Source: https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/UniqueDeviceIdentification/GlobalUDIDatabaseGUDID/UCM396592.xlsx)

So it does not require a prescription, but it also cannot be sold OTC. I'm not too familiar with medical device regs and what it actually means in practice if a medical device is neither Rx or OTC, but this does confirm that a prescription is not required for this device (at least not on the federal level, again, state regs may be more strict depending on the state).
 

giga

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The CDC has this resource for which states have restrictions on needle/syringe sales, but it's specific to whether you can sell to someone who you know is an IV drug user, which is a different than whether you can sell syringes to someone who you know is using it for prescription drug use: Laws Related to the Retail Sale of Syringes/Needles | Policy and Programs | Division of Viral Hepatitis | CDC. The analysis is almost two years old, so make sure to refer to your state board of pharmacy to confirm the most current rules.
 

disgonbgud

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https://www.walmart.com/ip/BD-SafetyGlide-Tuberculin-Syringe-1ml-26G-x-3-8-100ct/176521299
Apparently you can buy the tuberculin syringes from Walmart's pharmacy department in-store.

Personally I don't care for the phrasing "insulin syringes/needles only". Some patients administer B12 injections IM themselves and are sold the supplies in store, and although you technically could give insulin regular IM, you would of course strongly prefer SC for all insulins.
 

Charcoales

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Anyone have proof a RPH ever got in trouble for writing an rx for pen needles for a patient because the doctor forgot to write one? Wouldn't putting the pts needs first make u immune to bop or legal risk?
 

disgonbgud

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Anyone have proof a RPH ever got in trouble for writing an rx for pen needles for a patient because the doctor forgot to write one? Wouldn't putting the pts needs first make u immune to bop or legal risk?
No, breaking the law is breaking the law. You'd be committing prescription fraud.
According to the CDC, only TN and DE explicitly forbid selling needles by retail or to IVDU. The rest either explicitly allow it or have no direct law against it. Laws Related to the Retail Sale of Syringes/Needles | Policy and Programs | Division of Viral Hepatitis | CDC
 
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Anyone have proof a RPH ever got in trouble for writing an rx for pen needles for a patient because the doctor forgot to write one? Wouldn't putting the pts needs first make u immune to bop or legal risk?
I know of an rph who was terminated from their job and disciplined by BOP eventually losing their license for writing an rx for a patient when they did not follow through on their discipline. Putting the patients needs first by writing an rx unless you are legally allowed to do so is a HUGE mistake. If a patient needs needles and can legally buy them OTC then they can but them or wait until their provider writes an order.
 
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In reality, you give what you have. From a legal perspective, you cannot do so. You must turn away the prescription or order the product.

Sorry its an old post. What if its a refill and the rph had filled with a size different than the rx with no annotation of md being okay with it, do u still dispense?
 

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I was wondering what type of changes a pharmacist can do on non-controlled rx without the need to contact the prescribers first. For example, prescriber wrote 29g needles for insulin pens but it's not available. Can a pharmacist switch it to 30g or 31g without needing to confirm with them?
You can change careers without contacting a prescriber.
 

mentos

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If you guys are so worried about pen needles why don't you just sell them OTC? Aren't they cheap?
 

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BenJammin

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We can't do anything really without the doc approving it. In Texas you can't even fill 30 days of a 90 day supply rx without physician authorization. You just need to inform them if you're doing 30 to 90 but 90 to 30 requires the doc to authorize it.
 
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BidingMyTime

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. You just need to inform them if you're doing 30 to 90 but 90 to 30 requires the doc to authorize it.
That is completely crazy. So, if someone's insurance doesn't pay for 90 days, they are stuck until the dr can be contacted for a 30 day supply. I can see a medical justification for requiring 30 to 90 to be approved, but absolutely none for 90 to 30.
 

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https://www.walmart.com/ip/BD-SafetyGlide-Tuberculin-Syringe-1ml-26G-x-3-8-100ct/176521299
Apparently you can buy the tuberculin syringes from Walmart's pharmacy department in-store.

Personally I don't care for the phrasing "insulin syringes/needles only". Some patients administer B12 injections IM themselves and are sold the supplies in store, and although you technically could give insulin regular IM, you would of course strongly prefer SC for all insulins.
Ny for sure
 

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Unless I am unaware of some very new practice, I as an RN ,working ICU, ER , Diabetic Education & a variety of diabetic associated areas, when do you give & why administer IM insulin? On the counter side you would not want to increase the "psi" of administering an IM injection w a smaller needle/syringe. As a self injector of both Depo & B12, even after many years, I still need to psych myself out a bit. Even though I know its not painful. If I were a physician Id likely require the pt to demonstrate their technique & ability to correctly self administer IM meds.