What size topical to dispense?

[Sparda29]

In the case where a doctor fails to write the quantity that he wants dispensed on a topical medication? Do you guys dispense the larger quantity, or a smaller quantity? I've worked with two pharmacists who have completely opposing views on this, based on the solution I came up with.

For example, we got this script.

Bactroban Cream

Apply to Affected Area TID

Dispense: 1 month supply

Based, on my experience with topicals (acne stuff), a 60 gram tube lasts me about 7 days. So for this patient (Bactroban comes in 30 gram tubes), I'd dispense 240 grams of Bactroban cream.

I'd rather assume the area affected is large and give the patient an excess of medication instead of having them come back to me a week later bitching that they already ran out.

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[BugsNDrugs]

I, as well as the pharmacists (3 of them) who I work with all agree to dispense the largest size available. No one knows exactly how much area the topical has to cover, so we want to make sure they have enough. And besides, dispensing the large size means more money (well, most of the time).

 

[MountainPharmD]

In the case where a doctor fails to write the quantity that he wants dispensed on a topical medication? Do you guys dispense the larger quantity, or a smaller quantity? I've worked with two pharmacists who have completely opposing views on this, based on the solution I came up with.

For example, we got this script.

Bactroban Cream

Apply to Affected Area TID

Dispense: 1 month supply

Based, on my experience with topicals (acne stuff), a 60 gram tube lasts me about 7 days. So for this patient (Bactroban comes in 30 gram tubes), I'd dispense 240 grams of Bactroban cream.

I'd rather assume the area affected is large and give the patient an excess of medication instead of having them come back to me a week later bitching that they already ran out.

Why assume anything? Ask the patient how large the area is. Using your 6 years of pharmacy education you should be able to determine an adequate amount of cream or ointment to last the patient the required duration of therapy.

With that said one of my technicians used to be an auditor with Aetna. He told me one of Aetna's favorite audits was for creams and ointments. On cream and ointment prescriptions that did not specify a size, Aetna would kick back all claims if you dispensed more than the smallest pack size available for less than a 30-day supply.

So.....From a practical standpoint ask the patient how large the area is and dispense an appropriate amount. From a Pharmacy Manager standpoint, once you determine the proper amount call the Doctor and let them know what you dispensed. Get someone’s name and write on the script you called and verified the quantity.

 

[MountainPharmD]

I, as well as the pharmacists (3 of them) who I work with all agree to dispense the largest size available. No one knows exactly how much area the topical has to cover, so we want to make sure they have enough. And besides, dispensing the large size means more money (well, most of the time).

See my post above. Precisely why you will get audited and why they will take all the money back.

 

[BugsNDrugs]

See my post above. Precisely why you will get audited and why they will take all the money back.

Well, let me elaborate a little bit. Most of the Rx's we get don't even say "dispense 30 day supply". They just say "1 box" or "qs". So, in this case, we dispense what we think is "reasonable", and document on the hard copy. If the doctor doesn't specify a quantity, we assume they are leaving it up to the pharmacist to determine the amount to be dispensed. Been in business for 45 years, had SEVERAL audits, and has never been a problem doing it this way.

 

[njac]

Based, on my experience with topicals (acne stuff), a 60 gram tube lasts me about 7 days. So for this patient (Bactroban comes in 30 gram tubes), I'd dispense 240 grams of Bactroban cream.

I'd rather assume the area affected is large and give the patient an excess of medication instead of having them come back to me a week later bitching that they already ran out.

I'm not your dermatologist, but it sounds like you aren't using your acne products correctly. Less is more with retin-A. Ditto for any of the benzoyl peroxide products. Even if you applied over your entire face, not just affected areas, you should easily be able to have a 45g tube last a month.

Unless you're a pumpkin-head and your face is 10x the size of mine.

 

[BugsNDrugs]

Why assume anything? Ask the patient how large the area is. Using your 6 years of pharmacy education you should be able to determine an adequate amount of cream or ointment to last the patient the required duration of therapy.

With that said one of my technicians used to be an auditor with Aetna. He told me one of Aetna's favorite audits was for creams and ointments. On cream and ointment prescriptions that did not specify a size, Aetna would kick back all claims if you dispensed more than the smallest pack size available for less than a 30-day supply.

So.....From a practical standpoint ask the patient how large the area is and dispense an appropriate amount. From a Pharmacy Manager standpoint, once you determine the proper amount call the Doctor and let them know what you dispensed. Get someone’s name and write on the script you called and verified the quantity.

And let's be really "practical" here. I am sure you know that this happens quite often, usually several times per day. Do you really think it's "practical" to ask every patient how large the area is they are covering, and then reverse the claim you submitted earlier, recalculate, and redispense (assuming they don't wait on the Rx, which is the case with about 90% of patients)? Then you're going to call the doctor and let them know? Do you hold the Rx if the doctor isn't available (weekend, after hours)? Or are you going to give them the smallest size available, then wait for the doctor to call back, and then dispense the rest when you verify it? That could get expensive. I know what you are technically "supposed" to do, but we all know there are a lot of things in the practice of pharmacy that aren't done 100% by the book. Just seems like to me you are going to waste a lot of money and time doing things this way. Not to mention the doctor probably doesn't really even care when you call them about this. I think using your professional judgement and making the proper documentation is sufficient. But we all have our opinions.😉

 

[MountainPharmD]

And let's be really "practical" here. I am sure you know that this happens quite often, usually several times per day. Do you really think it's "practical" to ask every patient how large the area is they are covering.

Yes I do. Its called doing your job. Contrary to popular belief pharmacist are not supposed to stand behind the counter all day with their face glued to the verification screen making sure the pink pill in the bottle matches the pink pill on the screen. Unless of course you work for CVS or Walgreens. In that case that is all you do all day.

Then you're going to call the doctor and let them know? Do you hold the Rx if the doctor isn't available (weekend, after hours)? Or are you going to give them the smallest size available, then wait for the doctor to call back, and then dispense the rest when you verify it? That could get expensive. I know what you are technically "supposed" to do, but we all know there are a lot of things in the practice of pharmacy that aren't done 100% by the book. Just seems like to me you are going to waste a lot of money and time doing things this way.

You could make this argument for just about anything in the pharmacy. I do not know where you work or who you work with but there is never "a lot of things in the practice of pharmacy that aren't done 100% by the book." You do things the right way, the first time, everytime. This bull**** statement is made by sloppy, lazy pharmacists to justify why they are sloppy and lazy.

So what is next for you? Patient counseling...ehhh to time consuming. Calling Doctors on drug interacts, naw not enough time and they do not care anyway. Technician makes a mistake typing in the refills....ahhh forget it. It will take too long to change its only a few extra refills who cares. We have to remember the patient is waiting a god forbid they have to wait longer than 5 minutes.

 

[lorain]

give them the largest size and note on rx thats all we had in stock

but the acne stuff we give small bottles and bill as 30 d/s...as not much of that is used every day

 

[BugsNDrugs]

Yes I do. Its called doing your job. Contrary to popular belief pharmacist are not supposed to stand behind the counter all day with their face glued to the verification screen making sure the pink pill in the bottle matches the pink pill on the screen. Unless of course you work for CVS or Walgreens. In that case that is all you do all day.



You could make this argument for just about anything in the pharmacy. I do not know where you work or who you work with but there is never "a lot of things in the practice of pharmacy that aren't done 100% by the book." You do things the right way, the first time, everytime. This bull**** statement is made by sloppy, lazy pharmacists to justify why they are sloppy and lazy.

So what is next for you? Patient counseling...ehhh to time consuming. Calling Doctors on drug interacts, naw not enough time and they do not care anyway. Technician makes a mistake typing in the refills....ahhh forget it. It will take too long to change its only a few extra refills who cares. We have to remember the patient is waiting a god forbid they have to wait longer than 5 minutes.

Now I do agree with you 100% about these others scenarios you are talking about. Counseling a patient, catching errors, etc are obviously something to take seriously and should be checked and followed through on no matter what. If there is a drug interaction, then yes, absolutely, I would call the physician to let them know what's going on, regardless of whether I thought they would care or not. My comment about things not being done 100% apply to those matters that I don't consider "dangerous" if not done 100% by the book. If the doctor writes for a cream and you dispense the right product, but don't give a correct size, you're not going to do any harm to the patient. I guess I should rephrase the statement to say "there are a FEW things in the pharmacy practice, in terms of policies and procedures related to scenarios of this sort, that aren't done 100% by the book". But back to the topic at hand, I definitely have no problem with someone who wants to call the physician to verify a quantity of a topical product. There is NOTHING wrong with your argument. I am just saying, from the experience I have, after calling doctors on a regular basis for this exact same issue over and over, leaving messages on their voicemail about the issue and never hearing from them, or having the nurse say "Oh, I don't know how much to give them, just do what you think is best", I have found it much simpler to just use my judgement (or, the pharmacists') and give the patient what we think they should receive. We usually just give the largest size (not always, but often) so they will have enough and we document on the hard copy what we did. Like I said, it hasn't been a problem as far as audits. I have personally dealt with several audits myself when they come in to the pharmacy and I pull the scripts for them to look at. Not once has it been a problem. I'm not saying it couldn't potentially be a problem, we just haven't had it yet. Sorry I didn't clarify the first time.

 

[Thoughtfulsinner]

Doctor's have no idea what sizes to dispense. I swear some people on here don't think for themselves and would rather have a doctor tell them what size of tube to give a patient. Use your common sense and judgment to make the decision yourself. You can also look in their history and see how long they go in between refills for certain topical medications.

 

[MountainPharmD]

Doctor's have no idea what sizes to dispense. I swear some people on here don't think for themselves and would rather have a doctor tell them what size of tube to give a patient. Use your common sense and judgment to make the decision yourself. You can also look in their history and see how long they go in between refills for certain topical medications.

Thats how it works jackass. A Doctor writes a prescription and we fill it. A Doctor should know what size to dispense. Would you fill in the quantity on any other prescription? Why not? Doctor writes for Vicodin 1-2 q4-6h prn and no quantity. What do you do? Use your common sense and judgment to make the decision yourself and just pick a number because "some people on here don't think for themselves". Gimme a break.

Don't like the Vicodin example? Okay how about blood pressure meds or diabetes meds. The Doctor writes for Metformin 1000 BID and no qauntity. What do you do? Give the patient a 30 day supply? A 90 day supply? Some random days supply you just make up?

Or lets take it a step further. The Doctor leaves the directions off. Are you going to make up you own? Why not? Just use your common sense and judgment to make the decision yourself.

 

[MountainPharmD]

My comment about things not being done 100% apply to those matters that I don't consider "dangerous" if not done 100% by the book.

Great moral reasoning. I feel so much better. So it is okay to cut corners and not do things 100% by the book as long as you don't consider it "dangerous." You have alot to learn.

Use that line of reasoning with the State Board of Pharmacy or the DEA when they come to inspect and your pharmcy is all jacked up. But, but....its okay its not like it is "dangerous"

 

[BugsNDrugs]

Thats how it works jackass. A Doctor writes a prescription and we fill it. A Doctor should know what size to dispense. Would you fill in the quantity on any other prescription? Why not? Doctor writes for Vicodin 1-2 q4-6h prn and no quantity. What do you do? Use your common sense and judgment to make the decision yourself and just pick a number because "some people on here don't think for themselves". Gimme a break.

Don't like the Vicodin example? Okay how about blood pressure meds or diabetes meds. The Doctor writes for Metformin 1000 BID and no qauntity. What do you do? Give the patient a 30 day supply? A 90 day supply? Some random days supply you just make up?

Or lets take it a step further. The Doctor leaves the directions off. Are you going to make up you own? Why not? Just use your common sense and judgment to make the decision yourself.

Come on man. You're using examples that are totally different than topicals. Of course you will call for a quantity on something else, especially a control. I think you're fishing in the wrong place for your examples. We're talking about topicals here.

Great moral reasoning. I feel so much better. So it is okay to cut corners and not do things 100% by the book as long as you don't consider it "dangerous." You have alot to learn.

Use that line of reasoning with the State Board of Pharmacy or the DEA when they come to inspect and your pharmcy is all jacked up. But, but....its okay its not like it is "dangerous"

Once again, I am referring to TOPICALS not having a quantity on the Rx. No, I do not think that it is dangerous to give somebody a 15gm tube of cream versus a 30gm tube. Other things, such as our signature pad, are things that aren't done right 100% of the time, and I do not consider dangerous if not done correctly ALL the time. I refuse to believe that you do EVERYTHING exactly how it should be done, 100% all the time. In terms of filling a prescription with the right drug, checking it twice, counseling, checking for interactions, etc I hope you actually do everything 100% by the book. Again, PLEASE READ THAT LAST LINE CAREFULLY. I am not saying that I "cut corners" on important aspects of filling a prescription. I am saying that filling a prescription for a topical product that has no quantity indicated is not a big issue. I would be shocked if there were many pharmacists out there that call on EVERY SINGLE topical Rx they get that doesn't have a quantity on it. And please, I seriously doubt the board of pharmacy or the DEA is going to come knocking down our pharmacy door because I dispensed a 30gm tube of kenalog instead of a 15gm tube. Give me break.

So this argument between me and you is over. I think that it's okay in a lot of circumstances to fill a topical Rx if there is no quantity and fill it with your best judgement. You say call the doctor no matter what. Discussion closed. Have a great day!

 

[BugsNDrugs]

http://forums.studentdoctor.net/showthread.php?t=325194

I know I said the argument is over, but I couldn't help but point this out when I stumbled across it. Seems like you support my way of thinking that calling the physician can be a nightmare. Seems like you DON'T, in fact, do EVERYTHING by the book 100% of the time. Good day.

 

[cycloketocaine]

And please, I seriously doubt the board of pharmacy or the DEA is going to come knocking down our pharmacy door because I dispensed a 30gm tube of kenalog instead of a 15gm tube. Give me break.

No, but the insurance company you are billing it to will come knocking down your door.

 

[MountainPharmD]

http://forums.studentdoctor.net/showthread.php?t=325194

I know I said the argument is over, but I couldn't help but point this out when I stumbled across it. Seems like you support my way of thinking that calling the physician can be a nightmare. Seems like you DON'T, in fact, do EVERYTHING by the book 100% of the time. Good day.

Did you read the thread you referenced above? We were never discussing how difficult it is to call a Doctor with a simple question. The reason I started that thread was for me to vent about how hard it is to call with a simple question. Never once did I say I was giving up calling Doctors and I was going to do whatever I wanted in the future. You are trying to convince me that it is okay to bend the rules as long as it is not “dangerous."

Get your one-track mind off the cream or ointment example. I am using your rationalization as an example of the slippery slope you get on when you started deciding to “bend the rules”.

I am not saying that I "cut corners" on important aspects of filling a prescription. I am saying that filling a prescription for a topical product that has no quantity indicated is not a big issue........I seriously doubt the board of pharmacy or the DEA is going to come knocking down our pharmacy door because I dispensed a 30gm tube of kenalog instead of a 15gm tube.

Where do you draw the line? You do not "cut corners" on important aspects of filling a prescription? What the hell does this mean? If you are willing to cut corners on the so-called non-important aspects of filling a prescription what else are you willing to "cut corners" on? Narcotics discrepancies and incomplete or missing records are all things the DEA and BOP are interested in. Insurance companies are very interested in "cutting corners" such as incorrect days supply, brands billed for generics dispensed ect. All of the above areas I have seen sloppy/lazy pharmacists get into trouble over. The same pharmacists who justify there sloppiness and lazziness by saying they don't cut corners on the important stuff. Yeah right....

 

[Aznfarmerboi]

Yup, mountain is right. Always dispense smallest size unless you document how much is needed via patient or prescriber. Insurance audits will rape you...

 

[Thoughtfulsinner]

Thats how it works jackass. A Doctor writes a prescription and we fill it. A Doctor should know what size to dispense. Would you fill in the quantity on any other prescription? Why not? Doctor writes for Vicodin 1-2 q4-6h prn and no quantity. What do you do? Use your common sense and judgment to make the decision yourself and just pick a number because "some people on here don't think for themselves". Gimme a break.

Don't like the Vicodin example? Okay how about blood pressure meds or diabetes meds. The Doctor writes for Metformin 1000 BID and no qauntity. What do you do? Give the patient a 30 day supply? A 90 day supply? Some random days supply you just make up?

Or lets take it a step further. The Doctor leaves the directions off. Are you going to make up you own? Why not? Just use your common sense and judgment to make the decision yourself.

You call me a jackass, I call you a *******. Judging by this post, I bet you equate speeding with murder.

 

[BugsNDrugs]

Did you read the thread you referenced above? We were never discussing how difficult it is to call a Doctor with a simple question. The reason I started that thread was for me to vent about how hard it is to call with a simple question. Never once did I say I was giving up calling Doctors and I was going to do whatever I wanted in the future. You are trying to convince me that it is okay to bend the rules as long as it is not “dangerous."

Get your one-track mind off the cream or ointment example. I am using your rationalization as an example of the slippery slope you get on when you started deciding to “bend the rules”.



Where do you draw the line? You do not "cut corners" on important aspects of filling a prescription? What the hell does this mean? If you are willing to cut corners on the so-called non-important aspects of filling a prescription what else are you willing to "cut corners" on? Narcotics discrepancies and incomplete or missing records are all things the DEA and BOP are interested in. Insurance companies are very interested in "cutting corners" such as incorrect days supply, brands billed for generics dispensed ect. All of the above areas I have seen sloppy/lazy pharmacists get into trouble over. The same pharmacists who justify there sloppiness and lazziness by saying they don't cut corners on the important stuff. Yeah right....

Okay, I'm done. Sorry I ruffled your feathers. I didn't really think about it earlier, but I guess everything involved with actually filling the Rx IS important. I can't think of anything that I "cut corners" on while actually filling the Rx. I was talking more about things involved with store policy, rather than filling the Rx.

Enough of the back and forth argument. Have a great week.

 

[Old Timer]

This is one of those times you get to use your professional judgment. You look at the drug, the prescriber and you speak to the patient. If you are able to document why you gave any particular size, you will not have a problem with the insurance company. The only caveat is items that are very expensive, e.g. Clobex Solution or Shampoo.

Scenario One: Mycolog II cream disp 1 tube. Apply to vulva BID. Give a 15 gm and call it a day.

Scenario Two: Diprolene Oint disp 1 tube. Apply to rash BID. Now you ask the patient a few questions to determine what the rash is and how much of the skin is involved. Pt says it's a dot on my forearm, a 15 gm tube. Pt says poison ivy all over both legs a 50 gm tube. Rx documented appropriately.

So to review, it depends on the doctor, the patient and the drug involved. If you cannot elucidate from the patient, the appropriate size, then you contact the physician and ask what the dx is and how large of any area is involved so you can select the appropriate size.

 

[MountainPharmD]

Okay, I'm done. Sorry I ruffled your feathers. I didn't really think about it earlier, but I guess everything involved with actually filling the Rx IS important. I can't think of anything that I "cut corners" on while actually filling the Rx. I was talking more about things involved with store policy, rather than filling the Rx.

Enough of the back and forth argument. Have a great week.

Dude you did not ruffle my feathers! We were having a spirited discussion on a topic we both have a definite opinion on. You have your opinion and I have mine. Nothing to be upset about.

I thought you were done?

 

[MountainPharmD]

You call me a jackass, I call you a *******. Judging by this post, I bet you equate speeding with murder.

Ummmm...you lost me there. Speeding with murder....uhhh okay.

I will conceed I am a ******* if you conceed you are a jackass then we can move on with our lives.

 

[johnep34]

No arguement in UK where supplied under NHS. The govnmt will only pay for the smallest pack where 1 op is prescribed.
johnep