Why can't pharmacists change brand name to generic?

[Rouelle]

The more interesting part is the corporate espionage and subterfuge which resulted in millions of "patient" complaints forced the FDA to change their ruling on the AB ratings for Concerta and its generics.

We must have missed the episode of Dr Oz in which he educated the general public about Concerta

Nice use of the word “subterfuge,” btw

---

Members don't see this ad.

 

[CetiAlphaFive]

We must have missed the episode of Dr Oz in which he educated the general public about Concerta

Nice use of the word “subterfuge,” btw

Did you know there's 75mg of MERCURY in every tablet prior to 2010?

That's why Ford has secret back channels in the company

 

[txpharmguy]

Why can't they get their med?

I think Centalphi meant rx was sent in but drug was OOS. Wouldn't get medication until Monday afternoon. CIIs aren't transferable

 

[wucool33]

I think Centalphi meant rx was sent in but drug was OOS. Wouldn't get medication until Monday afternoon. CIIs aren't transferable

That’s not what he meant...

 

[Apotheker2015]

I’m quickly losing track of who’s being sarcastic vs who’s being serious on this thread

For the record. Moi: 100% serious.

 

[Apotheker2015]

I've never gotten a call back on any of my Concerta prescriptions, so I don't know what to tell you. The prescription always has Concerta by name but I always sign the substitution permitted line. Maybe South Carolina Pharmacy law is more lenient and letting them change it as they need to, I have no idea. I just know that I don't get call backs on this one.

I have no idea what AB rating means.

I think the insult in your post was unnecessary.

You were insulted by that?
That aside, I stated facts. You should know what AB rating is. We spend time making sure that we know how to communicate with physicians and speak your lingo. "Be right, be brief, be gone" is drilled in our heads very early in pharmacy school.
You should try to speak "pharmacist", as well. Think about it. If you write for Concerta, you are prescribing for either the brand name or the equivalent that shares the same release mechanism. Otherwise, you should write for methylphenidate ER if it does not matter to you. I think it should matter to you, but hey, it's your license.
A physician waltzes in here talking down to pharmacists as if we'd barely graduated from high school and you have the audacity to jump on that wagon and then get offended when some of us spell out the truth for you?

Only the italicized line was sarcastic. Just trying to help @Rouelle here.

 

[Apotheker2015]

In California there are two cudgels called California Code of Regulations, section 1716 and California Code of Regulations, section 1762 that board inspectors dual wield to beat pharmacists over the head (issue citations and fines for non-compliance). There are similar regulations for pharmacy acts or equivalent in other states.

You might say the BOP won't know unless they get reported, but it takes only one complaint out of thousands of Rx. In fact I even had a punk prescriber complain to the BOP because he didn't maintain control of his ****ing security prescription forms and a pharmacist happened to fill a fake RX at MY pharmacy, so I get to write an action plan and save this RPH's ass from a citation. So now we get to call for EVERY controlled Rx with any inkling of "uncertainty" of legitimacy

I think prescribers in all states should have some awareness of why they get these seemingly trivial requests for Rx changes and FIX the underlying reason for these requests.

EXACTLY... they go to bed thinking... these dumb pharmacists won't stop calling...
Right... it's not quite like, doc.

 

[headortail]

I don't think docs need to know these mechanisms right off the bat... Plenty of things that don't concern their practice directly that I wouldn't expect them to know, unless they're a specialist. Antiarrhythmics management by family practice? Not likely; I can give them some info on those meds. Would I be schooling an electrophysiologist on antiarrhythmics? Not likely, but that doesn't mean I can't serve as a double check, and a lot of times things get missed because doctors are also humans and have like 5 seconds to put in orders/write rx discharge/write their 3 page note, it's inevitable.

What they do need to, though, is to listen for a just a few seconds, then they will eventually pick up on stuff like Concerta or AB rating. We can learn plenty from them just as they can from us. There are docs out there who try to pick up stuff from everyone - RNs, dieticians, pharmacists etc and don't look at it as a blow to their ego "how dare you challenge my authority ", rather after a while they become super knowledgeable and are a joy to work with. But boy aren't they the unicorns.

 

[Apotheker2015]

I don't think docs need to know these mechanisms right off the bat... Plenty of things that don't concern their practice directly that I wouldn't expect them to know, unless they're a specialist. Antiarrhythmics management by family practice? Not likely; I can give them some info on those meds. Would I be schooling an electrophysiologist on antiarrhythmics? Not likely, but that doesn't mean I can't serve as a double check, and a lot of times things get missed because doctors are also humans and have like 5 seconds to put in orders/write rx discharge/write their 3 page note, it's inevitable.

What they do need to, though, is to listen for a just a few seconds, then they will eventually pick up on stuff like Concerta or AB rating. We can learn plenty from them just as they can from us. There are docs out there who try to pick up stuff from everyone - RNs, dieticians, pharmacists etc and don't look at it as a blow to their ego "how dare you challenge my authority ", rather after a while they become super knowledgeable and are a joy to work with. But boy aren't they the unicorns.

It's hard not to generalize, of course. I do get a lot of calls that are basically either the doc or nurse can look it up on lexicomp OR I can interrupt the Henry Ford line and wait for Lexicomp to load on my Walmart station and look it up for them. Or they call you, the pharmacist, to get a recommendation for a drug but you don't have access to the chart. It's grey. I try to limit what I tell them to facts. Per X study, this drug was only studied in ages X to Y and the study found that doses over 40 mg per day showed no additional benefit and increased risk of whatever in patient with whatever.
But I make no decisions for them. They don't get to write. Per the pharmacist's recommendation... we are prescribing this over that. At a hospital or in a VA setup, sure, I am all for recommendations because I'd have access to the chart but in retail, I only put my license behind facts that I can reference.

 

[rx1983]

Agree, they should at least know it exists because maybe then they'd understand there's a difference, most importantly a 150 times price difference, between the generic for Glucophage XR and Glumetza so they stop selecting the Glumetza generic in the system then wonder why they get a PA request wasting our time and the patient's. Happens all the time.

You should know about the osmotic release
Mechanism because it’s beautiful. It’s how Concerta got the patent. Furthermore, if your script does not specify you want us to substitute with a he AB rated methylphenidate, then that’s just sloppy.

Being more familiar with these things would make it less annoying for you when we call you save your sorry physician license. If I had a dollar for every sloppy prescription I’ve gotten, my loans would be paid off.

Seriously...

 

[CetiAlphaFive]

It's hard not to generalize, of course. I do get a lot of calls that are basically either the doc or nurse can look it up on lexicomp OR I can interrupt the Henry Ford line and wait for Lexicomp to load on my Walmart station and look it up for them. Or they call you, the pharmacist, to get a recommendation for a drug but you don't have access to the chart. It's grey. I try to limit what I tell them to facts. Per X study, this drug was only studied in ages X to Y and the study found that doses over 40 mg per day showed no additional benefit and increased risk of whatever in patient with whatever.
But I make no decisions for them. They don't get to write. Per the pharmacist's recommendation... we are prescribing this over that. At a hospital or in a VA setup, sure, I am all for recommendations because I'd have access to the chart but in retail, I only put my license behind facts that I can reference.

Pharmacists for a company used to have access to charts and literally everything else in regular, retail outpatient.
It was great.

Then, one idiot pharmacist checked his technician's chart because she called in sick during a busy day.

They canned him, and, instead of being reasonable and forcing outpatient to do training, they yanked access for all of the outpatient pharmacies.

It sucked.

 

[VA Hopeful Dr]

You were insulted by that?
That aside, I stated facts. You should know what AB rating is. We spend time making sure that we know how to communicate with physicians and speak your lingo. "Be right, be brief, be gone" is drilled in our heads very early in pharmacy school.
You should try to speak "pharmacist", as well. Think about it. If you write for Concerta, you are prescribing for either the brand name or the equivalent that shares the same release mechanism. Otherwise, you should write for methylphenidate ER if it does not matter to you. I think it should matter to you, but hey, it's your license.
A physician waltzes in here talking down to pharmacists as if we'd barely graduated from high school and you have the audacity to jump on that wagon and then get offended when some of us spell out the truth for you?

Only the italicized line was sarcastic. Just trying to help @Rouelle here.

Which would be why I almost always write for the brand and sign for generic substitution to be allowed (I only don't for super old things when I don't even know the brand name for like penicillin). I'm trusting you to dispense the generic that behaves the same way as the brand.

Since pharmacists exist, and there is a mechanism in place for me to essentially say "give the patient the generic equivalent to drug X", what purpose does it serve for me to learn the different rating systems for said generic drugs?

I didn't say I was insulted. One can recognize an insult without being insulted.

 

[Apotheker2015]

Which would be why I almost always write for the brand and sign for generic substitution to be allowed (I only don't for super old things when I don't even know the brand name for like penicillin). I'm trusting you to dispense the generic that behaves the same way as the brand.

Since pharmacists exist, and there is a mechanism in place for me to essentially say "give the patient the generic equivalent to drug X", what purpose does it serve for me to learn the different rating systems for said generic drugs?

I didn't say I was insulted. One can recognize an insult without being insulted.

Well, this is what everyone is trying to tell you. That is not quite how it works. There are laws. Just like we take a law exam, so do you. If that was not on yours, well, that’s the reason we are required to keep current on updates to the law.

Knowing that there’s something unique about concerta and that only two genérics are equivalent would improve your practice, workflow, reduce the number of phone calls you get.

If you write for concerta, we have to dispense the genetic that has the same unique osmotic release mechanism. Plain and simple. Switching to methylphenidate ER is not an option. Doing so would be changing one drug for another. It might as well be lisinopril.

No one is saying you have to memorize the Orange book. Knowing it exists and having access to it, would improve your practice. Acting like it’s beneath you definitely won’t.

Give these terms some thought:

1. Pharmaceutical equivalent
2. Pharmaceutical alternative
3. Therapeutic equivalent
4. Bioequivalence

Those 4 terms are the reason people are telling you this is important for you to know.

In case you didn’t know, “there’s an app for that”. There’s an Orange Book App.

We are there to double check your work and offer advice whether solicited or unsolicited. When unaware of the rules, we have no other option to make you aware of the rules.

Saying that there’s no need for you to know this since that’s what pharmacists are there for makes no sense. Knowing about drug shortages, drug recalls, new generics available that are AB rated or aren’t. But if you choose to practice medicine that way, then sure, go ahead. No explanation is needed. It’s sloppy, though. But hey, it’s your license.

 

[VA Hopeful Dr]

Well, this is what everyone is trying to tell you. That is not quite how it works. There are laws. Just like we take a law exam, so do you. If that was not on yours, well, that’s the reason we are required to keep current on updates to the law.

Knowing that there’s something unique about concerta and that only two genérics are equivalent would improve your practice, workflow, reduce the number of phone calls you get.

If you write for concerta, we have to dispense the genetic that has the same unique osmotic release mechanism. Plain and simple. Switching to methylphenidate ER is not an option. Doing so would be changing one drug for another. It might as well be lisinopril.

No one is saying you have to memorize the Orange book. Knowing it exists and having access to it, would improve your practice. Acting like it’s beneath you definitely won’t.

Give these terms some thought:

1. Pharmaceutical equivalent
2. Pharmaceutical alternative
3. Therapeutic equivalent
4. Bioequivalence

Those 4 terms are the reason people are telling you this is important for you to know.

In case you didn’t know, “there’s an app for that”. There’s an Orange Book App.

We are there to double check your work and offer advice whether solicited or unsolicited. When unaware of the rules, we have no other option to make you aware of the rules.

Saying that there’s no need for you to know this since that’s what pharmacists are there for makes no sense. Knowing about drug shortages, drug recalls, new generics available that are AB rated or aren’t. But if you choose to practice medicine that way, then sure, go ahead. No explanation is needed. It’s sloppy, though. But hey, it’s your license.

I have never taken a law exam of any kind. Majority of states don't require it for physician licensure.

So I asked around to other physicians I know (total of 10 in the last week). None of them knew what AB rating meant either beyond "something to do with generic meds".

I can also promise you that not knowing about generic ratings, shortages, or recalls does not put my license in any danger but the snark is surely appreciated.

 

[Sparda29]

To the OP:

Would you rather deal with a pharmacist who is gonna call you for everything? Or would you prefer someone who will automatically change it to whatever is covered without calling you?

 

[Rouelle]

I have never taken a law exam of any kind. Majority of states don't require it for physician licensure.

So I asked around to other physicians I know (total of 10 in the last week). None of them knew what AB rating meant either beyond "something to do with generic meds".

I can also promise you that not knowing about generic ratings, shortages, or recalls does not put my license in any danger but the snark is surely appreciated.

So I think you came here with a legitimate question/frustration and are getting an unnecessary amount of snark. Sorry for that...

Here’s the AB thing: We have a book (or online resource) called the Orange Book. With it we can look up a specific drug product made by a specific manufacturer and compare to another product. If they are deemed equivalent, then they are said to be AB rated and can be substituted one for the other, assuming you guys don’t prescribe a specific manufacturer or write Dispense as Written. There are a variety of other alphabetic ratings that mean various things, but the bottom line is drugs with those other ratings cannot be substituted in most states. This comes up a lot with things like diltiazem, methylphenidate, etc where there are many different approved dosage forms that are not identical.

Hope this helps.

 

[VA Hopeful Dr]

So I think you came here with a legitimate question/frustration and are getting an unnecessary amount of snark. Sorry for that...

Here’s the AB thing: We have a book (or online resource) called the Orange Book. With it we can look up a specific drug product made by a specific manufacturer and compare to another product. If they are deemed equivalent, then they are said to be AB rated and can be substituted one for the other, assuming you guys don’t prescribe a specific manufacturer or write Dispense as Written. There are a variety of other alphabetic ratings that mean various things, but the bottom line is drugs with those other ratings cannot be substituted in most states. This comes up a lot with things like diltiazem, methylphenidate, etc where there are many different approved dosage forms that are not identical.

Hope this helps.

The snark doesn't bother me personally (God knows y'all get **** from doctors often enough that I don't mind when someone gets snippy with me, it seems fair), I'm still just honestly confused why I would need to know about different generic ratings so long as my prescription is written for the brand but with the "Substitution Permitted" line signed. I don't mean to sound like a jerk, but isn't it the pharmacist's responsibility to make sure the generic is equivalent to the brand? Hence why everyone here knows about AB ratings and whatnot.

 

[Rouelle]

The snark doesn't bother me personally (God knows y'all get **** from doctors often enough that I don't mind when someone gets snippy with me, it seems fair), I'm still just honestly confused why I would need to know about different generic ratings so long as my prescription is written for the brand but with the "Substitution Permitted" line signed. I don't mean to sound like a jerk, but isn't it the pharmacist's responsibility to make sure the generic is equivalent to the brand? Hence why everyone here knows about AB ratings and whatnot.

Agreed. Was just giving you the background info since everyone kept referring to it.

 

[Apotheker2015]

The snark doesn't bother me personally (God knows y'all get **** from doctors often enough that I don't mind when someone gets snippy with me, it seems fair), I'm still just honestly confused why I would need to know about different generic ratings so long as my prescription is written for the brand but with the "Substitution Permitted" line signed. I don't mean to sound like a jerk, but isn't it the pharmacist's responsibility to make sure the generic is equivalent to the brand? Hence why everyone here knows about AB ratings and whatnot.

Call the board of pharmacy and ask for yourself. No one is trying to misinform you here. We cannot just change a brand name drug to a generic that is not AB rated because it is unlikely to be a therapeutic equivalent or bioequivalent, even though it is a pharmaceutical equivalent (same active ingredient) but likely a pharmaceutical alternative (same active ingredient, different dosage form/release mechanism).
I hope that helps.

 

[genesis09]

You can't forget the purple book. It is the one which lists biosimilar and interchangeable biosimilar drugs. Not all biosimilars are interchangeable to the original product.

 

[owlegrad]

You can't forget the purple book. It is the one which lists biosimilar and interchangeable biosimilar drugs. Not all biosimilars are interchangeable to the original product.

This is basically a novelty at this point. How many interchangeable biosimilars are currently on the market? I think maybe 2 were recently approved?

 

[genesis09]

This is basically a novelty at this point. How many interchangeable biosimilars are currently on the market? I think maybe 2 were recently approved?

Right now there is not a whole lot of them. I don't know if there are any interchangeable biosimilars around. However, they will become more numerous. It's just a matter of time. We should be aware of the differences between generics and biosimilars.

 

[thecoolpharmboi]

Today I sent over an rx for Concerta to the pharmacy. This is in Texas btw.

15 minutes later I get a phone call from the pharmacist at CVS.

Pharmacist: Their insurance won't cover brand name, can you switch to generic?
Me: Why are you calling me? Can't you switch it over on your own?
Pharmacist: Well not really...
Me: Fine then, absolutely, go ahead and change it to generic methylphenidate
Pharmacist: I need your approval to switch it
Me: Why?
Pharmacist: I cant change it without your approval
Me: OK you have my approval
Pharmacist: I need a new prescription sent over
Me: So you went to 4 years of pharmacy school and you don't have approval to switch brand names to generics?
Pharmacist: Ummm

WTF is this? It's not just schedule IIs either, it happens every day. It's not just CVS either, it's every pharmacy.

Is this a Texas deal? I have no idea why a board certified pharmacist doesn't have the authority to switch meds like this. Surely this can't be real in 2018.

I thought the pharmacist was pulling a practical joke on me. 4 years in a PharmD program and they can't switch to generic? How are you guys going to become "health care providers" when you can't even switch brand to generic? Unbelievable....

I’m a pharmacist working in Texas and we substitute Concerta for methylphenidate ER all the time as well as other branded medications. only reason I see why they would be calling if the E-scripts says brand medically necessary (DAW1)/ no substitutions allowed OR the brand to generic is not therapeutically equivalent.

Only other times I see brand vs genetics issue is insurance but in your case I don’t think that applies.

 

[thecoolpharmboi]

This does not apply to BX rated Concerta generics, but:

My state allows a patient to override a DAW1. Simply document that “pt prefers generic” and you’re fine. So when we get a script for Omnicef DAW1, we simply tell the patient something along the following lines: “Your dr wrote for brand name Omnicef. We don’t keep that in stock because it has been available as a generic for so long. I can see if I can order it for you. If so, it will be tomorrow evening, at the earliest, before I can get it and your copay will be $XX.XX. If you want, I can get you the generic today for $X.XX.” Document and done.

If it’s a DAW1...how do you just override it without contacting the prescriber? Legally we can’t do that as far as I know...

 

[BidingMyTime]

Which would be why I almost always write for the brand and sign for generic substitution to be allowed (I only don't for super old things when I don't even know the brand name for like penicillin). I'm trusting you to dispense the generic that behaves the same way as the brand.

Off topic, but I once worked in an area with a doctor who always checked the "May sub" box....EXCEPT when he wrote for penicillin, then he always checked the "dispense as written" box. I really don't think he understood what the sub/don't sub boxes even meant.

 

[CetiAlphaFive]

I’m a pharmacist working in Texas and we substitute Concerta for methylphenidate ER all the time as well as other branded medications. only reason I see why they would be calling if the E-scripts says brand medically necessary (DAW1)/ no substitutions allowed OR the brand to generic is not therapeutically equivalent.
Only other times I see brand vs genetics issue is insurance but in your case I don’t think that applies.

You should really take the time to call the board and get clarification on whether or not you can dispense a Pill that doesn't say "ALZA" on it for a script with "concerta" written on it.

 

[Apotheker2015]

If it’s a DAW1...how do you just override it without contacting the prescriber? Legally we can’t do that as far as I know...

Yeah, it's odd but it's a nice provision to have. My state allows that, as well. It also works the other way around. If there is no DAW and the patient prefers the brand name, that takes precedence and you can override. It may cause issues with insurance on subsequent fills but it will go through the first time. Have seen that happen. Insurance will want the patient to go through the PA process.

 

[panicatthepharmacy]

I’m a pharmacist working in Texas and we substitute Concerta for methylphenidate ER all the time as well as other branded medications.

Yeah, but the REAL question is: would you transfer it out to another pharmacy if it wasn't filled yet?

 

[CetiAlphaFive]

Pharmacists can't change it because they're not providers thus have no real responsibilities bro. They just lick, stick, and pour.

> couldn't even get into an MD program
> criticizing Pharm.Ds


Thanks for your input, "doctor"

 

[Socrates25]

To the OP:

Would you rather deal with a pharmacist who is gonna call you for everything? Or would you prefer someone who will automatically change it to whatever is covered without calling you?

Absolutely change it without wasting my time and wanting me to send over another prescription.

I'm just shocked at how pharmacists in this country want to run their own clinics like diabetes or coumadin but somehow can't be bothered to change brand to generics or just generally look for alternatives instead of throwing their hands up and saying "it's not covered, call your doc and get a new script" crap.

 

[Socrates25]

Had yet another example come up today....

As you guys know, epi-pens are a real cluster**** right now. My patient needed a refill so I sent in an epi-pen prescription. Some insurances wan't me to write for brand name, some will cover only generic. I have no idea how to tell which is which unless I want to spend 30 minutes on an insurance company phone line talking to some bureaucrat. Ain't nobody got time for that. So, I send in the epi-pen script, but I specifically make sure the "substitution allowed" box is checked.

Of course the pharmacist calls and tells me it's $400 and wants to know if there's an alternative I'd like to use.

I answer -- well, what alternatives are available? He says "well you can send over generic epinephrine"

I said "great idea, you can switch it for me right"

His answer: "nope I need a new script"

Unbelievable. You guys can independently change dosing for insulin or coumadin with no MD oversight whatsoever, yet you need my approval and a new script to change from epi-pen to generic epinephrine.

 

[gwarm01]

Had yet another example come up today....

As you guys know, epi-pens are a real cluster**** right now. My patient needed a refill so I sent in an epi-pen prescription. Some insurances wan't me to write for brand name, some will cover only generic. I have no idea how to tell which is which unless I want to spend 30 minutes on an insurance company phone line talking to some bureaucrat. Ain't nobody got time for that. So, I send in the epi-pen script, but I specifically make sure the "substitution allowed" box is checked.

Of course the pharmacist calls and tells me it's $400 and wants to know if there's an alternative I'd like to use.

I answer -- well, what alternatives are available? He says "well you can send over generic epinephrine"

I said "great idea, you can switch it for me right"

His answer: "nope I need a new script"

Unbelievable. You guys can independently change dosing for insulin or coumadin with no MD oversight whatsoever, yet you need my approval and a new script to change from epi-pen to generic epinephrine.

I don't want to shock you here, but Joe ******* who is afraid of switching tabs to caps with a CYA call probably isn't the same person working in these clinics.

 

[owlegrad]

Unbelievable. You guys can independently change dosing for insulin or coumadin with no MD oversight whatsoever, yet you need my approval and a new script to change from epi-pen to generic epinephrine.

The first part of that is false, we are required to have collaborative practice agreements to do any of that in every state that I know of.

For the second part, you are conflating two separate issues. We cannot change medications for drugs that are not "AB" rated in the FDA Orange Book in most states (some states have other, more vague standards that must be followed). So Epipens cannot legally be changed to "generic" epinephrine in most states without a new script. Is the system stupid? Absolutely, but it is what it is.

Why that pharmacist didn't just take a verbal script rather than make you send in a new one is a mystery to me, but perhaps it was punishment for a perceived poor attitude on the prescriber's side. Alternatively perhaps they feared an insurance chargeback and decided it was safer to require a new script be sent in. Lots of pharmacists run their pharmacies in all kinds of (to me weird/stupid) ways. Personally I would have just notated on the script that the prescriber wanted the generic without wasting everybody's time with a worthless phone call and went on with my day, but to each their own.

 

[aznsensazn3]

I don't understand why the mylan EpiPen generic is bx rated to the brand. It's the same auto injector device. I change between the mylan brand and generic per insurance and patient preference without calling the doctor. I won't change it to the lineage generic (technically adrenaclick generic) without a new script. The adrenaclick generic has a second cap and could be dangerous if not properly trained how to use and remove that second cap.

 

[genesis09]

The generic epinephrine pens are generics of adrenaclick not epi-pen. All you have to do is to write ok to switch to adrenaclick on the rx.

 

[Sine Cura]

Authorized generics have no bioequivalence rating because they are merely relabeled.

 

[ldiot]

Not all menthylphenidate generics can be substituted for Concerta, and it just so happens that the specific generic that every insurance company covers is not an approved sub for Concerta. It's just a weird issue with this particular medication. So just write the script for methylphenidate. Pharmacists are scared to switch it themselves because it's a CII.

 

[ldiot]

I don't think docs need to know these mechanisms right off the bat... Plenty of things that don't concern their practice directly that I wouldn't expect them to know, unless they're a specialist. Antiarrhythmics management by family practice? Not likely; I can give them some info on those meds. Would I be schooling an electrophysiologist on antiarrhythmics? Not likely, but that doesn't mean I can't serve as a double check, and a lot of times things get missed because doctors are also humans and have like 5 seconds to put in orders/write rx discharge/write their 3 page note, it's inevitable.

Don't kid yourself. A cardiologist today told me that carvedilol only has beta activity.

 

[W19]

Don't kid yourself. A cardiologist today told me that carvedilol only has beta activity.

Hard to believe...

 

[CetiAlphaFive]

Absolutely change it without wasting my time and wanting me to send over another prescription.

I'm just shocked at how pharmacists in this country want to run their own clinics like diabetes or coumadin but somehow can't be bothered to change brand to generics or just generally look for alternatives instead of throwing their hands up and saying "it's not covered, call your doc and get a new script" crap.

The problem here is that you think the pharmacist does anything special when they call the insurance.

As far as I'm concerned, you or your nurses can call the insurance or submit an appeal

 

[VA Hopeful Dr]

So quick question for your pharmacist folks:

If I write for a 90-day supply, can y'all change to 30 day supplies with 2 refills on your own authority? And vice versa?

 

[ifillrxs]

So quick question for your pharmacist folks:

If I write for a 90-day supply, can y'all change to 30 day supplies with 2 refills on your own authority? And vice versa?

According to the pharmacy law in my state, I can reduce the quantity but cannot increase the quantity. So I can change 90 into 30 plus 2 refills. I CANNOT change 30 plus two refills into 90.

To my knowledge, all states can reduce the quantity but only some can increase it. My advice is to write all maintenance meds for 90 day supply to allow me the discretion to split it up if necessary.

On another topic, since you're soliciting advice and I love to hit the easy button, write for "albuterol inhaler" or "prenatal vitamin" to allow me to choose what is best for the patient.

 

[Rouelle]

So quick question for your pharmacist folks:

If I write for a 90-day supply, can y'all change to 30 day supplies with 2 refills on your own authority? And vice versa?

Yes, we can dispense any quantity up to a maximum of 90 day supply in your example. So if insurance will only do 30 days at a time, we can do that without calling you. If a patient only wants to pick up 2 days worth of Suboxone, we can do that.

My state just allowed us (within the last year or so) to convert 30 day supplies of maintenance meds (non-controlled, of course) with an appropriate number of refills to 90 day supplies without contacting the prescriber. As stated above, this is state-specific.

 

[VA Hopeful Dr]

According to the pharmacy law in my state, I can reduce the quantity but cannot increase the quantity. So I can change 90 into 30 plus 2 refills. I CANNOT change 30 plus two refills into 90.

To my knowledge, all states can reduce the quantity but only some can increase it. My advice is to write all maintenance meds for 90 day supply to allow me the discretion to split it up if necessary.

On another topic, since you're soliciting advice and I love to hit the easy button, write for "albuterol inhaler" or "prenatal vitamin" to allow me to choose what is best for the patient.

Ugh, my EMR doesn't let me free-type prescriptions.

 

[Greeney]

So quick question for your pharmacist folks:

If I write for a 90-day supply, can y'all change to 30 day supplies with 2 refills on your own authority? And vice versa?

I'm not sure where you're located, but in Nevada the answer is yes. First, we will always dispense the quantity as prescribed by you UNLESS the pt's insurance does not allow for 90 days (we would then make it 30 days + 2 refills) OR if the pt specifically asks for a lower quantity (the remaining quantity would then stay on the pt's Rx as refills). This is not the case for CII's however. For CII's we may dispense less only if the remaining quantity is forfeited, and any requests for more of that drug requires a new prescription.

A prescribed quantity of 30 + 2 refills may be automatically changed to 90 + 0 refills only if the pt has had that drug at least once before. However, some insurances actually require 90 day supplies for certain drugs. In that case, we make the call to your office to request a 90 day.

 

[CetiAlphaFive]

So quick question for your pharmacist folks:

If I write for a 90-day supply, can y'all change to 30 day supplies with 2 refills on your own authority? And vice versa?

In Texas, yes.

Some pharmacists don't like to, but the only l requirement for some TPPs is to fax a notification to v the prescriber

 

[lane one]

Had yet another example come up today....

As you guys know, epi-pens are a real cluster**** right now. My patient needed a refill so I sent in an epi-pen prescription. Some insurances wan't me to write for brand name, some will cover only generic. I have no idea how to tell which is which unless I want to spend 30 minutes on an insurance company phone line talking to some bureaucrat. Ain't nobody got time for that. So, I send in the epi-pen script, but I specifically make sure the "substitution allowed" box is checked.

Of course the pharmacist calls and tells me it's $400 and wants to know if there's an alternative I'd like to use.

I answer -- well, what alternatives are available? He says "well you can send over generic epinephrine"

I said "great idea, you can switch it for me right"

His answer: "nope I need a new script"

Unbelievable. You guys can independently change dosing for insulin or coumadin with no MD oversight whatsoever, yet you need my approval and a new script to change from epi-pen to generic epinephrine.

It sounds like your beef is with regulatory bodies, but for some reason you insist on killing the messenger. I also think it's hilarious that you don't have time to talk to some "insurance company bureaucrat" but you think the pharmacist with the 3 lane drive-thru has 30 min to spare.

 

[Sine Cura]

In CA, one thing I like is that I can always cite BPC 4052.5 when it comes to auto-changing caps to tabs for A/NDA drug products "when the change will improve the ability of the patient to comply with the prescribed drug therapy." What better way to improve the ability of the patient to comply with the prescribed drug therapy than changing to what is covered or what actually exists. Of course one caveat being that will you document to survive an insurance audit. And this doesn't cover doxycline mono vs hyclate but no one smart cares about that when it comes to formulary limitations

It's the old RPH that apparently did not pay attention to the law portion when studying for CPJE that get skittish about freaking Qvar vs Redihaler (LOL) or ODT ondansetron vs regular ondansetron or ferrous sulfate EC vs not-ec, ranitidine tabs vs caps and so on. You could even change diphenhydramine 12.5 mg tabs to liquid. Lantus vs Basaglar same deal as insulin glargine is not a BLA product.

 

[BidingMyTime]

Unbelievable. You guys can independently change dosing for insulin or coumadin with no MD oversight whatsoever, yet you need my approval and a new script to change from epi-pen to generic epinephrine.

He should have wrote it down as a verbal order, I'm not aware of any state in which a verbal order for the change of a non-C drug is not allowed.

So quick question for your pharmacist folks:
If I write for a 90-day supply, can y'all change to 30 day supplies with 2 refills on your own authority? And vice versa?

Depends on the state, in Illinois yes, we can legally dispense any amount that is less than or equivalent to the original qty + refills (upto a a limit of 30 days on CII's, 6 months on other C's and 1 year on other drugs.) If you wrote for Cardizem 30 + 12 refills, and the pt wanted to pay cash (since no ins will pay for this much), then they could get 365 days worth at once. If you wrote for Ambien 30 + 12 refills (which I've seen prescribers do, even though they shouldn't), and the pt wanted to pay cash, then they could get 180 days worth at once (although because it is a controlled, I think most pharmacists would not fill that much at once without verifying the extenuating circumstance, ie the pt would be out of the country for 6 months or something like that.)

It's the old RPH that apparently did not pay attention to the law portion when studying for CPJE that get skittish about freaking Qvar vs Redihaler (LOL) or ODT ondansetron vs regular ondansetron or ferrous sulfate EC vs not-ec, ranitidine tabs vs caps and so on. You could even change diphenhydramine 12.5 mg tabs to liquid. Lantus vs Basaglar same deal as insulin glargine is not a BLA product.

OK, I'm an old RPH, but what are you talking about? It is clearly not legal to change dosage forms without talking to the doctor. Probably most doctors wouldn't care and don't want to be called about these changes, but legally speaking these aren't changes the pharmacist can do on their own.

 

[Sine Cura]

OK, I'm an old RPH, but what are you talking about? It is clearly not legal to change dosage forms without talking to the doctor. Probably most doctors wouldn't care and don't want to be called about these changes, but legally speaking these aren't changes the pharmacist can do on their own.

I am referring to the California regulation BPC 4052.5 so pharmacists working in California