Walmart control policy change?

[Wickett]

I have heard vaguely from friends that Walmart has introduced more strict control fill policies this year. I am curious about what others have noticed with this (either direct Walmart pharmacists or those that have a Walmart near their pharmacy). Where I work, it is pretty much us and Walmart in town. They used to be real loosey goosey on filling controls (my refusals would always end up there). Now, this Walmart seems to be refusing EVERYTHING that is a pain control.

I am getting flooded everyday with customers coming from there, saying they were told the pharmacy could no longer order tramadol, tylenol with codeine, norco, etc. It isn't just the shady people they are refusing either.....I get several a day with low quantity pain meds after oral surgery, etc being refused across the board by Walmart for a one time pain med fill. I spoke to the manager there and after making vague statements on corporate policy changes, the dude claimed things were on back order (we get our meds from the same supplier and have seen no shortages). What gives? Is this just a location going overboard with a new policy or is this the new norm at Walmart?

I checked the state board site and didn't see any infractions against them to indicate something had happened to make them this gun shy. Our control % has almost doubled in the past couple months and we have basically turned into Walmart's satellite control fill pharmacy. I have started to tell patients that I will fill this first pain fill, but if they want it regularly, they need to transfer their general medications over to us so we can more safely monitor for any potential interactions. I figure if they are going to send us every control filler in town, we should at least get their other meds as well. Any input is appreciated.

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[lord999]

It's actually going to come up at the next MN board meeting as the two "Wal"'s have sent written policy changes in response to the "Prince Act" that basically leans heavily in favor of refuse except for chronic customers and those who are terminal. There are reports that the Walmart's at two of the outlying county seats in upstate are indiscriminately refusing all urgent care scripts that have drawn a number of patient complaints. Locally, since Prince died, some pharmacies just refuse to fill any remotely questionable prescriptions out of liability headache concerns, patient sales be damned. It's a refreshing change from the old Wal-Mart attitude that every customer is a $100k and that we need to always make them happy.

The interesting professional practice problem is that the way the Practice Act is written, pharmacists may refuse for no reason at all, so long as it's not an illegal reason (racism, etc.). Practitioner boycotts are a well-known quiet control policy in the state, and I wonder if it is going to require legislation to address again.

 

[Wickett]

It's actually going to come up at the next MN board meeting as the two "Wal"'s have sent written policy changes in response to the "Prince Act" that basically leans heavily in favor of refuse except for chronic customers and those who are terminal. There are reports that the Walmart's at two of the outlying county seats in upstate are indiscriminately refusing all urgent care scripts that have drawn a number of patient complaints. Locally, since Prince died, some pharmacies just refuse to fill any remotely questionable prescriptions out of liability headache concerns, patient sales be damned. It's a refreshing change from the old Wal-Mart attitude that every customer is a $100k and that we need to always make them happy.

The interesting professional practice problem is that the way the Practice Act is written, pharmacists may refuse for no reason at all, so long as it's not an illegal reason (racism, etc.). Practitioner boycotts are a well-known quiet control policy in the state, and I wonder if it is going to require legislation to address again.

Interesting...thanks for the info. I definitely understand being strict about controls (my pharmacy used to be the "strict" one in town because I didn't fill things indiscriminately or more than 2 days early). However, at least where I'm at, its getting ridiculous. They are simply refusing everything, both chronic and acute. I guess the upside is that it can drive business over to my pharmacy, but it just seems like they are swinging from one extreme side of the pendulum to the other.

 

[cj98]

Yes, Walmart started limiting acute opioids to a max of 7 days or 50mg MME. So even if the dr prescribed something like Tylenol #3 or Tramadol with refills, we are required to void out the refills and only dispense a 7 day supply if for an acute condition. For chronic pain conditions or a cancer dx or palliative care, we can fill the full quantity, however this requires documentation that the opioid is used for a chronic condition. Our training stated that if the patient doesn't agree with this, then we can let them know to use another pharmacy. Not sure about other stores, but ever since the new policy, we are getting less shipment of controls from our warehouse, so it is true that we are always out of stock.

 

[Wickett]

Yes, Walmart started limiting acute opioids to a max of 7 days or 50mg MME. So even if the dr prescribed something like Tylenol #3 or Tramadol with refills, we are required to void out the refills and only dispense a 7 day supply if for an acute condition. For chronic pain conditions or a cancer dx or palliative care, we can fill the full quantity, however this requires documentation that the opioid is used for a chronic condition. Our training stated that if the patient doesn't agree with this, then we can let them know to use another pharmacy. Not sure about other stores, but ever since the new policy, we are getting less shipment of controls from our warehouse, so it is true that we are always out of stock.

Good to know more details. I guess this location is just going a bit overboard (they won't even fill a 4 day supply of tylenol 3 for post surgical pain). I wish this particular pharmacy would try to explain to the patients why they are refusing the prescription...they are just telling everyone they can't get any more pain meds and that we have it in stock.

 

[lord999]

Yes, Walmart started limiting acute opioids to a max of 7 days or 50mg MME. So even if the dr prescribed something like Tylenol #3 or Tramadol with refills, we are required to void out the refills and only dispense a 7 day supply if for an acute condition. For chronic pain conditions or a cancer dx or palliative care, we can fill the full quantity, however this requires documentation that the opioid is used for a chronic condition. Our training stated that if the patient doesn't agree with this, then we can let them know to use another pharmacy. Not sure about other stores, but ever since the new policy, we are getting less shipment of controls from our warehouse, so it is true that we are always out of stock.

Wow, I'm going to be surprised how that's going to go over in TX, where quantity alterations like that are actually against their practice act (pharmacies may not alter quantity on dispense except for stockout reasons which the completion must be carried out).

 

[Carbon14]

Walmart and Sam’s Club will restrict initial acute opioid prescriptions to no more than a seven-day supply, with up to a 50 morphine milligram equivalent maximum per day. This policy is in alignment with the Centers for Disease Control and Prevention’s (CDC) guidelines for opioid use. Where state law for fills on new acute opioid prescriptions is less than seven days, Walmart and Sam’s Club will follow state law.

Additionally, as of Jan. 1, 2020, Walmart and Sam’s Club will require e-prescriptions for controlled substances. E-prescriptions are proven to be less prone to errors, they cannot be altered or copied and are electronically trackable.

Further, by the end of August 2018:

In states that allow access, the company’s pharmacists will have access to and use the controlled substance tracking tool, NarxCare. NarxCare is a tool that helps pharmacists make dispensing decisions and provides pharmacists with the real-time interstate visibility that currently exists.

Source: Walmart Introduces Additional Measures to Help Curb Opioid Abuse and Misuse

 

[Gombrich12]

The walmart by my pharmacy is telling everyone they are out of norco and percocet. It's going to suck to be the PIC at the local competitor when some lunkhead DEA agent comes in and asks why you're dispensing so many more controls than the walmart across the street.

 

[Sine Cura]

This MME <50/7 day limit for acute Rx made the news but WM, at least in my region, has been requiring pharmacists be more aggressive in scrutinizing chronic opioid regimens for the past year. "They" don't want pharmacists in a position to try to explain to the BoP or DEA why the same opioid regimen, especially high TDD MME, is being dispensed to a patient without variation for years and years without any sort of substantive documentation or why no tapering is being done. With the CDC guidelines being invoked anything above 90 MME for non-cancer pain is being scrutinized far more heavily than in the past. Also any irrational regimens like Norco 10/325 #180 or #240 that can be converted to ATC long-acting with BTP regimen (but haven't) are considered problematic


You can tell the difference compared to 2016. Stores in the Methstate (of northern California) previously around ~15% controls last year are now below 10%.

WM DC is not supplying controls anymore so it is technically true the DC is out of stock.

More discussion at Reddit suggesting there is regional variation in how WM is handling "opioid stewardship" for chronic opioid therapy
Link 1

Link 2

I find it interesting that pharmacists are willing to take the time to talk to opioid patients about their regimen, meds tried and failed, adjunctive therapy etc. I am really not interested in talking to patients unless I am flat out refusing to fill something completely untenable

 

[Charcoales]

Wonder if one can simply not order any c2 in anymore, there by truly being out of stock at all times..

 

[Carbon14]

The OOS simply coincides with a transition to a new supply chain. When a behemoth implements such major changes, it's never a smooth process.

This article explains a part of why such major changes were implemented:

McKesson Agrees to Pay Record $150 Million Settlement for Failure to Report Suspicious Orders of Pharmaceutical Drugs

I would assume McKesson is also playing it safe during the transition period. It's easier to limit the supply of these drugs in order to minimize litigation.

Charcoales- if I understand your question correctly: intentionally not ordering narcotics which are readily available for delivery through the supplier is against the policy. Pharmacists that choose to exploit this loophole are being screened for internally and will be reprimanded or outright terminated for denying patient care. Hiding behind 'sorry, were out of stock' holds up for a week or two, a month, but corporate catches on quick.