Unique emergency supply situation

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g40631

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Just to clarify. I didn't run it as a partial in the pharmacy computer system. I merely reprinted a label and gave him 3 tablets out of the 30 ct bottle and placed it in a different bottle.
 
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g40631 said:
Just to clarify. I didn't run it as a partial in the pharmacy computer system. I merely reprinted a label and gave him 3 tablets out of the 30 ct bottle and placed it in a different bottle.
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In this case, I don't think the 72 hour rule applies.

We have a hard-and-fast policy about not loaning controls at our pharmacy.
 
Right, I understand the logistics about loaning out controls to someone. This isn't, in my opinion, the usual definition of "loaning," at least how we describe it. We have a valid rx, the patient just has an issue with payment. With just 3 pills loaned and the fact that the patient obviously needs the rx, we're obviously going to see the patient within 72 hours anyways (it was just 3 pills).
 
g40631 said:
Just to clarify. I didn't run it as a partial in the pharmacy computer system. I merely reprinted a label and gave him 3 tablets out of the 30 ct bottle and placed it in a different bottle.
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Well, unless my memory is off, if the label says 30, but you only gave him 3, its considered misbranded RX. Not right, but probably not as bad as partial filling a C2. :D
 
Cross out the number and write 3?

You guys aren't giving me a lot of confidence right now, lol
 
g40631 said:
Cross out the number and write 3?

You guys aren't giving me a lot of confidence right now, lol
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I wouldn't recommend it. If it says 3, then it's a partial fill. Misbranded RX might be argued as negligence, not sure you can say the same if you did a partial fill when it's not out-of-stock.

You might be able to dispense all 30, but charge them the discounted price, and have them do an IOU then price modify when the card arrives. But don't know what your management would say about that.
 
xiphoid2010 said:
I wouldn't recommend it. If it says 3, then it's a partial fill. Misbranded RX might be argued as negligence, not sure you can say the same if you did a partial fill when it's not out-of-stock.

You might be able to dispense all 30, but charge them the discounted price, and have them do an IOU then price modify when the card arrives. But don't know what your management would say about that.
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So when a patient is out of refills on their warfarin, their 90 and nearly blind, and it's Friday night; do you not loan them 3 tablets to hold them over the weekend while you wait for a new script because crossing out the quantity on the label you re-printed is misbranding? Also, the date the script was dispensed is also invalid, as may be the RPh who filled the prescription.
 
Or how about just hand-writing "1 of 2" and "2 of 2" on the label; then dispense the 3 tablets of loaned CII in 1 vial and the other 27 in the other vial? That way the patient is getting the full quantity as indicated on the label, just in different vials. We do this all the time for your Vicodin ES, Metformin 1,000, and large quantity gabapentin scripts.
 
g40631 said:
So when a patient is out of refills on their warfarin, their 90 and nearly blind, and it's Friday night; do you not loan them 3 tablets to hold them over the weekend while you wait for a new script because crossing out the quantity on the label you re-printed is misbranding? Also, the date the script was dispensed is also invalid, as may be the RPh who filled the prescription.
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You can partial fill warfarin, and it is fully legit to dispense 3 and print a partial label saying 3 tabs.

You can't partial fill a C2, as it forfeits the rest of the quantity (unless it's because pharmacy is out of stock.)
 
g40631 said:
Or how about just hand-writing "1 of 2" and "2 of 2" on the label; then dispense the 3 tablets of loaned CII in 1 vial and the other 27 in the other vial? That way the patient is getting the full quantity as indicated on the label, just in different vials. We do this all the time for your Vicodin ES, Metformin 1,000, and large quantity gabapentin scripts.
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Interesting thought, i'm not sure what's the legal implication of that.
 
xiphoid2010 said:
You can partial fill warfarin, and it is fully legit to dispense 3 and print a partial label saying 3 tabs.

You can't partial fill a C2, as it forfeits the rest of the quantity (unless it's because pharmacy is out of stock.)
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Correct, but in this scenario, the medication was actually dispensed completely pursuant to the order. Only in this scenario, the patient was unable to purchase the medication so 3 tablets we're removed from the bottle and placed in a different bottle until they could furnish payment. Do you think this meets the legal definition of a partial fill?
 
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The 72 hou rule only applies when the pharmacy is short of the whole quantity. In your case, technially, is a partial fill and the remaining quantity is lost. Partial fills are only ok in a hospice situation but I don't remember the details of doing it. In your case, its illegal but it would be borderline impossible to get in trouble unless they don't pick up the remaining quantity or they get the rest and then claim you shorted them 3 pills.
 
g40631 said:
Correct, but in this scenario, the medication was actually dispensed completely pursuant to the order. Only in this scenario, the patient was unable to purchase the medication so 3 tablets we're removed from the bottle and placed in a different bottle until they could furnish payment. Do you think this meets the legal definition of a partial fill?
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Here is what i think: If the system says you dispensed 30, but you only gave them 3, then it's misfill/misbranding. If the system says you dispensed 3, then it's a partial fill and legally you can not dispense the remaining 27. If the system says you dispensed 30, you dispensed 30, but only charged them a lower price (sounded like they are self pay), then it's legally ok, but you'll have to explain what/why to your boss. :)
 
npage148 said:
The 72 hou rule only applies when the pharmacy is short of the whole quantity. In your case, technially, is a partial fill and the remaining quantity is lost. Partial fills are only ok in a hospice situation but I don't remember the details of doing it. In your case, its illegal but it would be borderline impossible to get in trouble unless they don't pick up the remaining quantity or they get the rest and then claim you shorted them 3 pills.
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Ok, but if they don't pick up the remaining quantity, why not just run the rx for 3 tablets? The rest of the remaining quantity is lost then but the patient didn't come in to pick it up anyways. This guy is not going to claim I shorted him 3 pills, I am confident.
 
xiphoid2010 said:
Here is what i think: If the system says you dispensed 30, but you only gave them 3, then it's misfill/misbranding. If the system says you dispensed 3, then it's a partial fill and legally you can not dispense the remaining 27. If the system says you dispensed 30, you dispensed 30, but only charged them a lower price (sounded like they are self pay), then it's legally ok, but you'll have to explain what/why to your boss. :)
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The former.
 
g40631 said:
Hey there, so I was faced with an interesting scenario today. A patient came in to pick up scripts for him and his sons. One of the scripts was for a CII (stimulant). He tried to use his Flex card but it was expired. We were slow so we worked with him on the phone to try to get it authorized. Apparantally they had sent his card to the wrong address. I made the decision to float him a 3 day supply of the meds so that they wouldn't go without therapy. The patient knew where the card was sent and I told him to just get a hold of it and bring it in the next couple days.

My question is: I have a valid rx on file for the CII. It isn't a partial fill from the usual definition of the term (i.e. pharmacy didn't have enough to fill it entirely). Does the DEA regulations regarding having the remaining quantity dispensed within 72 hours still apply when we're simply holding the patient over so he can obtain payment?

Anyone encounter such a situation before?

Thanks
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Actually i have done that before for non controlled drugs . I will never do that for controlled substances . If they never come to get it , you will lose 3 tablets. not a good thing if you ask me
 
ancienbon said:
Actually i have done that before for non controlled drugs . I will never do that for controlled substances . If they never come to get it , you will lose 3 tablets. not a good thing if you ask me
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But realistically is a regular customer who took his kid to the doctor for an ADHD script, with a kid throwing tantrums everyday and not doing homework etc., really going to NOT come back for the meds that his son takes chronically?
 
...all of this sounds like too much paranoia.

They should have just paid cash and then done an exchange whenever they got the right FSA card.
 
I don't lend C2's like that just to avoid discrepancies altogether. I don't know if I would say what you did was "illegal" persay, but it's more of a gray area. You clearly thought it was in the patient's best interest, but as far as partial fill vs. lending, I think it depends on how they were charged and how it was documented.
 
The problem was with payment, not filling or inventory. You should have either had them pay, then re-bill when they had the appropriate card, or let them submit the receipt to the company for reimbursement. The latter happens all the time when people have a problem with their flex card.

If it was too expensive for him to pay upfront and get reimbursed, you would fill it as a X day's supply (in your case 3) and then get a new rx filled at the end of those 3 days. The new rx could be a full 30, wouldn't have to be 27. That would be the "boy scout" 100% legal way, which probably would not happen in most pharmacies.
 
I actually had a situation where there was a prior authorization on a c-II stimulant where the MD called us to authorize an emergency 72 hr fill on a medication. We basically are gonna take the amount out of the orginial fill once it goes through.
 
browneyes021 said:
I actually had a situation where there was a prior authorization on a c-II stimulant where the MD called us to authorize an emergency 72 hr fill on a medication. We basically are gonna take the amount out of the orginial fill once it goes through.
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MDs can't authorize that... even though they may think that they can. ;)
 
PharmDstudent said:
MDs can't authorize that... even though they may think that they can. ;)
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orly.jpg
 
PharmDstudent said:
MDs can't authorize that... even though they may think that they can. ;)
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I am in TN, it seems to me that an MD can do that as long as they mail you the paper rx in 48 or 72 hours of the verbal CII or you'll have to report them to the DEA for failing to do so. But I do not have my law books at home to look that info up. I don't remember if it is at the state or federal level.
 
owlegrad said:
orly.jpg
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Yes.


GabonpharmD said:
I am in TN, it seems to me that an MD can do that as long as they mail you the paper rx in 48 or 72 hours of the verbal CII or you'll have to report them to the DEA for failing to do so. But I do not have my law books at home to look that info up. I don't remember if it is at the state or federal level.
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That isn't the issue. It's an insurance problem, and CIIs can not be split up simply because of insurance problems. The customer always has the option to pay out of pocket, so that doesn't hold water.


This isn't a "unique emergency supply situation". It's an insurance problem.
 
PharmDstudent said:
Yes.


That isn't the issue. It's an insurance problem, and CIIs can not be split up simply because of insurance problems. The customer always has the option to pay out of pocket, so that doesn't hold water.


This isn't a "unique emergency supply situation". It's an insurance problem.
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I could not agree with you more. This is not an emergency issue, as the prescription was filled, and ready to be picked up. The patient should have paid cash, and come back when they get their insurance for a refund. So this issue does not belong to the 72 emergency supply when there is no refill, or the pharmacist is unable to get the hard copy.
 
What does the law call an emergency situation? What does the DEA have to say on the matter (this was already answered, but for some reason we are still talking about it)?
 
All4MyDaughter said:
I don't think they can. Are you talking about faxing?
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Per law, i think they can, at least in the state of Florida. However, the hard copy has to be received within 7 days or else, the prescriber should be reported to the DEA
 
Yeah, in FL we are permitted to follow the federal law, which does allow for it. I have never worked with a pharmacist who has done it though. In practice it is probably more trouble than it is worth, at least as far as a chain pharmacy would be concerned.
 
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ancienbon said:
I could not agree with you more. This is not an emergency issue, as the prescription was filled, and ready to be picked up. The patient should have paid cash, and come back when they get their insurance for a refund. So this issue does not belong to the 72 emergency supply when there is no refill, or the pharmacist is unable to get the hard copy.
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What if they couldn't pay cash because they didn't have the money? For example we have regular patients who are lower class and occasionally cannot pick up their scripts due to financial reasons. So if they are getting paid on Friday, and today is Tuesday and they do not have enough cash, we will front them three days worth of their already filled prescription for their clopidogrel, or a beta-blocker, or Atripla, or what have you (meds that can have risky repercussions if not taken compliantly). We do this because we actually care about our patients and want them to continue to trust our profession and do not want them to have bad outcomes. When they get paid they will pick up the remaining 27 days worth of medicine. We never had anyone take the meds and transfer pharmacies, or drop off the face of the planet. I feel that the oath of the pharmacist and ethics override the law in this case, and can be extrapolated to CIIs if it is done within reason and nothing is shady. Of course it has to be with regular patients who you have developed relationships with and have no question in your mind that they will be back to pay and pick up the rest. We are all professionals and the beauty of being professionals is we can use professional judgement in the gray zone in these types of situations. There generally isn't a right or wrong answer, but simply speculation of what the better/worse answers are (please correct me if I'm wrong about that).

But if he could've afforded to pay the cash I would've asked him to do that and refund the difference when he got the card. However, I'm not the pharmacist just yet, and when it comes to controlled substance scripts, I have no say at my store.

Just my two cents. Like I said everyone has their own opinion.
 
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I'm surprised that you haven't received verbal orders for an emergency CII before. I wouldn't say it's super common, but it certainly isn't extremely rare. It usually is for the maintenance patients who get the rx sent to them in the mail and they bring it in, but there is a holiday where the mail doesn't get delivered, but there are a few other times that it happens too.
 
Lol at the MDs opinion of a "emergency". The doctor said said it was an emergency because the patient could not have an interruption in their medication. I never thought my C-II emergency fill would be on a CNS stimulant as opposed to a pain medication. And the way the MD called it in was a douchebag way by saying that if we didn't give the patient an emergency supply for 72 hrs that he'd make sure we were held responsible for any damage caused to the patient for interrupting therapy. My techs flipped and said this particular MD has attitude and once told their past pharmacist that he'd choke her because she called for clarification on a prescription.
 
browneyes021 said:
Lol at the MDs opinion of a "emergency". The doctor said said it was an emergency because the patient could not have an interruption in their medication. I never thought my C-II emergency fill would be on a CNS stimulant as opposed to a pain medication. And the way the MD called it in was a douchebag way by saying that if we didn't give the patient an emergency supply for 72 hrs that he'd make sure we were held responsible for any damage caused to the patient for interrupting therapy. My techs flipped and said this particular MD has attitude and once told their past pharmacist that he'd choke her because she called for clarification on a prescription.
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:eek:
 
Thanks everyone for your advice.

I have another question. Can a patient request less of the medication then prescribed for a CII, and forfeit the remainder of the quantity? I.E. - The patient can only afford such and such amount and understands they would have to forfeit the remainder. Or is DEA law so strict that it requires the pharmacist to dispense the Rx completely despite the patient's request?? Thanks.

Oh and by the way, this is obviously not an "emergency supply" situation by the legal definition of the term. Emergency supply was a poor choice of words. Here, the patient had a standard month supply rx, just couldn't furnish payment. We're not dealing with a phoned in 72 hour emergency supply here. We're actually dealing with a hand-written rx.

The patient could not afford the cost of the medication out of pocket, by the way.
 
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g40631 said:
Can a patient request less of the medication then prescribed for a CII, and forfeit the remainder of the quantity? I.E. - The patient can only afford such and such amount and understands they would have to forfeit the remainder.
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Yes.
 
g40631 said:
Then in actuality, I'm worrying about nothing essentially.
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Did they forfeit the remaining 27? Or are they in for a surprise when they bring in the card only to be told that you can't dispense the rest? :)
 
owlegrad said:
What is the legal definition of the term?
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Scenario: Patient immediately needs CII drug (aka morphine) and the prescriber is out of town. Prescriber can phone in an emergency supply to the pharmacist to be deduced to writing. The quantity prescribed should not exceed the emergency period. The prescriber must then furnish a signed hard copy duplicating what was prescribed for the emergency supply period to the copy (either via mailing it to them, giving it to the patient to bring to the pharmacy {probably not the most reliable method}, or bringing it to them themselves), within 7 days of the order being transmitted via phone. If not, the pharmacist must report the prescriber to the DEA.

Feel free to correct me if you think I'm wrong.
 
owlegrad said:
You are adamant that a physician cannot call in a 72 hour emergency supply of CIIs?
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ancienbon said:
I could not agree with you more. This is not an emergency issue, as the prescription was filled, and ready to be picked up. The patient should have paid cash, and come back when they get their insurance for a refund. So this issue does not belong to the 72 emergency supply when there is no refill, or the pharmacist is unable to get the hard copy.
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^^^^ this
 
g40631 said:
Scenario: Patient immediately needs CII drug (aka morphine) and the prescriber is out of town. Prescriber can phone in an emergency supply to the pharmacist to be deduced to writing. The quantity prescribed should not exceed the emergency period. The prescriber must then furnish a signed hard copy duplicating what was prescribed for the emergency supply period to the copy (either via mailing it to them, giving it to the patient to bring to the pharmacy {probably not the most reliable method}, or bringing it to them themselves), within 7 days of the order being transmitted via phone. If not, the pharmacist must report the prescriber to the DEA.

Feel free to correct me if you think I'm wrong.
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That is exactly what I understand to be a CII 72 hour "emergency supply". It's for patients who *need* a CII and have no other way of getting it.

It's not for when: the doctor's office is still open, we don't have enough of the "Watson brand" (but we do have it in the "Teva brand"), we have enough in stock but they don't want to pay for it out of pocket or take a partial, etc.

It's for EMERGENCIES.

Think of a patient on a morphine drip that's about to dry up...
 
I hope I don't get blasted for this, but does anyone know what the law would say in this situation.....Depending on your relationship with the patient and the patient can't afford to pay the cash price for the whole prescription, is there anything against:

A. Paying the cash price yourself (basically floating them a loan) in the expectation that they will come back in a few days once the insurance situation is resolved. There's always the chance that they won't return and you're out the price of the script, so there is an inherent amount of risk. In essence, is it illegal for us to pay for our patient's scripts (as a courtesy) whether or not we are expected to be paid back?

B. Depending on your area of practice (independent vs. chain) can you extend to them a line of credit until the insurance issue is resolved? I don't know if this is done anymore, or even allowed, but I know that independent pharmacies used to extend a line of credit to patients as a courtesy in order to compete with the bigger chains.

I know this is probably complicating the situation even more, but I was looking to come up with an "outside the box" solution where you can dispense the whole prescription at one time. This also has the chance of setting a bad precedent, so it may not be the best idea. Thoughts?
 
CUpharmD2013 said:
I hope I don't get blasted for this, but does anyone know what the law would say in this situation.....Depending on your relationship with the patient and the patient can't afford to pay the cash price for the whole prescription, is there anything against:

A. Paying the cash price yourself (basically floating them a loan) in the expectation that they will come back in a few days once the insurance situation is resolved. There's always the chance that they won't return and you're out the price of the script, so there is an inherent amount of risk. In essence, is it illegal for us to pay for our patient's scripts (as a courtesy) whether or not we are expected to be paid back?

B. Depending on your area of practice (independent vs. chain) can you extend to them a line of credit until the insurance issue is resolved? I don't know if this is done anymore, or even allowed, but I know that independent pharmacies used to extend a line of credit to patients as a courtesy in order to compete with the bigger chains.

I know this is probably complicating the situation even more, but I was looking to come up with an "outside the box" solution where you can dispense the whole prescription at one time. This also has the chance of setting a bad precedent, so it may not be the best idea. Thoughts?
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I believe that A is sort of insurance fraud, since the terms with the company are that they will pay X% and the insured will pay the copay. Not paying the copay would violate that.

I'm not sure of the legality of B, but I know that an independent that I used to work for would do this. We'd hold all of their receipts and put it on "their account" and they would pay us around the first of the month, or whenever they were paid.
 
Ackj said:
I believe that A is sort of insurance fraud, since the terms with the company are that they will pay X% and the insured will pay the copay. Not paying the copay would violate that.

I'm not sure of the legality of B, but I know that an independent that I used to work for would do this. We'd hold all of their receipts and put it on "their account" and they would pay us around the first of the month, or whenever they were paid.
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I'm not suggesting that I (as the pharmacist) pays the copay for them. What I am suggesting is that we cover the cash price (if they cannot afford that) so that they can get the medication now and then when they get the insurance issue worked out in a couple days they would bring it back in, the cash price would be refunded (back to the pharmacist), the claim would be submitted, and the patient would pay their normal copay. It happens all the time with insurance issues, it's just different in this case because the cash for payment is coming from us rather than the patient. You're taking a leap of faith with the patient that they will indeed return. Again, I admit that there is a level of risk with this approach, so I would take my relationship with the patient into account. But this approach avoids a partial filling of a CII while at the same time getting the patient their medication without a lapse in treatment.
 
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