The Redheaded Pharmacist

11 Comments to “To Break Or Not To Break?”

1. By WillCall, August 9, 2012 @ 12:25 pm

   Don’t get me started. I work frequently in a store that has been through audits from hell, and has become anal retentive about days supply. Customers become irate when copay goes from $50.00 to $100.00 because the days supply has been accurately calculated according to the directions for “this” sell. I even had the customer service department from Express Scripts call me on the patient’s behalf and ask me why the copay had doubled from the last time. “Because your company audits our billing and they have demanded that we bill accurately according to the exact directions on the prescription, and ‘use as directed’ is not adequate directions.” Customer had already picked up prescription and then he has his doctor’s office escribe Rx with amount to be administered doubled. This change results in the customer returning Rx, and the store refunding Rx and then reselling with new label directions and reduced copay, and also call to insurance company to get them to pay for Rx with revised directions.

   Last night I had call from doctor’s office again about another customer and copay costs with Lantus. The nurse was calling on patient’s behalf and wanted to make sure that we got the new Rx with the new directions so the patient would get the lower copay, again customer had already picked up Rx with the previous directions. I explained the auditing practices and suggested that if the dose of insulin could vary, that the prescriber issue the Rx with instructions that the patient can give up to “x” number of units of insulin if the BS exceeds a certain level with “x” being the magic number with which we use to calculation the days supply.

     WillCall(Quote)
2. By Txpharmguy, August 9, 2012 @ 1:39 pm

   Most audits are triggered by >1 package size dispensed. Some software won’t even let you break the package size. I still dispense small package size available (ie, unopened box). I have a pt (vet pt) who gets Lantus Solostars one pen at a time but they’re a good customer and have been with us a while (dog only uses 3-5 units per day or something ridiculous) and a whole box is pretty darn expensive. We have to do this as a non-system drug to break the package. I wouldn’t however, do this for insurance purposes. If you have a situation where an insurance company audits for a 10 ml bottle for > 30 days supply because that’s the only way supplied, I’d appeal the hell out of that. Again, every audit I’ve ever been thru has been high unit utilization (>1 package unit dispensed). I’ve been thru Caremark, Medicaid, and Medco audits.

     Txpharmguy(Quote)
3. By Jeremy, August 9, 2012 @ 6:33 pm

   I had this very issue several years ago. The doctor demanded that I dispense the full box of 5 pens for a patient that only used 2 pens a month and her insurance would only pay for 30 day supply of medication. I called the manufacturer and they said they had requirement that the box not be broken.

     Jeremy(Quote)
4. By LDPlaceboeffect, August 9, 2012 @ 9:12 pm

   Wow. I never thought there was a reason other than pharmacist/pharmacist owner self-indulgence in making a patient pay the whole shebang in refusing to open a sealed package of anything. ‘Course, when I was a new grad, we never took back drugs and sold them to the next customer. In the hospital, unit-of-use packaging allowed return of stock back and forth from this location to that.

   I would never sell a used bottle of insulin as I would not sell an ointment tube missing its protective seal. Nor, would I sell an opened plastic package of syringes, but I would have absolutely no problem purchasing an individual pen from a pharmacy. Now, if it were a gas station, I might have some hesitancy, but for the love of pete, a pharmacist doesn’t get all het up about opening stock bottles of oral dosage forms and filling literally thousands of prescriptions for capsules or whatever that will be ingested, even by sick people!

   Just as I have no problem purchasing a hand-compounded ointment without a manufacturer’s seal from a pharmacist, I would have no problem with unpunched-out partial unit-dose cards.

   My dog uses 2 units of Lantus twice a day. That is 4 units daily. A 10 mL vial has 1,000 units in it. There are no 3 mL vials of Lantus, only 3 mL pens.

   Pens are great and availability of an option such as the technology of a measurable mosquito bite insulin deliver device option is a joy to teach a newly diagnosed patient to use for best control of the circadian and other rhythms.

   But, once opened a vial of insulin is only good for 28 days. Which I’m inclined to believe is justifiable. Whether it’s the 5th day or the 21st time that vial is poked by a needle not under aseptic conditions always introduces the factor of a stray foreign body and the possibility of lipodystrophy and insulin resistance.

   So, being a pharmacist. Do I spend $150.00 for a 10 mL vial of insulin that I have only used 112 units? Or, do I shell out $250.00 for the mandatory purchase of 5 pens, for each I will have to waste almost 2/3 because of priming 2 units for each dose? Or, do I ask the pharmacist to sell me one pen at a time, in case my little doggie’s dose changes and I’m out xx amount of money for a changed prescription?

   As pharmacist’s we tend to go along with the drug manufacturer stories a little too zealously while escaping the commonsense interpretation.

     LDPlaceboeffect(Quote)
5. By RxBoy, August 9, 2012 @ 10:17 pm

   Oh yes, I can relate to this. A while back we lost a lot of money in an audit due to this sort of thing. As a result of that, we now will not fill any prescriptions for things such as insulin or warfarin if they simply say “use as directed” in the directions. We are required to contact the doctor and at least get a maximum daily dose to add to the directions so that the auditor can’t challenge us on a days supply issue.

   As far as pre-packaged medications, we don’t break up insulin pens. Even if we did, this wouldn’t solve the problem. What about inhalers, nasal sprays, eye drops, etc. We can’t break those up. Some of the PBMs will override a days supply if we are using the smallest pack size available, but there is one that won’t even do that. Anything over 30 days supply must be purchased through the mail-order pharmacy.

   I remember one day a mother came in with an rx for Flonase for her daughter who was stuffed up and sick with a bad cold. The way the doctor wrote the directions made the bottle come out to a 60 day supply. It rejected for a maximum days supply of 30 and I called them to request an override. They refused to override it saying that since it was going to last more than 30 days the patient must buy it through mail order. The mother was not happy, but at least she understood it wasn’t our fault.

   I think the best thing for us to do is make sure we are following all the rules of these PBMs to avoid loosing money in audits. I just wish the angry patients would direct their frustration where it should be going. Instead of taking it out on me I wish they would go complain to their union, HR department, or whoever else is responsible for picking their plan. That’s the only way things are going to change.

     RxBoy(Quote)
6. By Amy, August 9, 2012 @ 10:19 pm

   An auditor told me once that you have to process a claim with the package size and days supply as written (i.e. 15 ml and 45 days). If it rejects then you can bill as 30 day supply with a notation. You have to do this every time. The only problem I ever had doing it that way is if a 45 day supply was covered (people don’t like to pay 2 co-pays if they are used to paying the 1 for the same package). I always hated dispensing 6 tabs of imitrex.

     Amy(Quote)
7. By Davis, August 10, 2012 @ 12:04 pm

   We are not allowed to break packages, ever.

     Davis(Quote)
8. By Rx observer, August 10, 2012 @ 5:44 pm

   D** those pesky patients anyway that want to buy one pen at a time, or can only afford one pen at a time. It might be interesting to see actual figures of how much prescription business is done for pets and small humans. Another question…how much drug production is wasted to begin with with companies selling short-dated products, setting what seems to be arbitrary expiration dates, and forcing square pegs of what a patient needs into the round holes of what the insurance companies so graciously ‘allow’?

   Sooo, it seems WE pharmacists are supporting this monkey-business for convenience of insurance companies (the business school majors, statisticians, and those in the actuarial sciences) that work within the group insurance models, and have not a clue about pathophysiology. Nothing at all to do with ‘packaging for individual sales’ or ‘possibly number of days quantities’.

   True democracy in action. No time for individuals. But, we knew tha all the time anyway, the moment we started paying in and receiving the benefits of employer-group insurance.

     Rx observer(Quote)
9. By Morgan, August 11, 2012 @ 6:32 pm

   I have a question for the pharmacist. I am prescribed a controlled substance for my adhd. Last month my doctor gave me my rx for the month plus a second one for this month. The date that he wrote on the second script was the same date as the one for last month (July 13th for the first script and August 13th for the second script). There is just one problem…there were 31 days in the month last month, therefore I will be without my medication for a day. I am wondering two things, is there any way the pharmacy can fill on the 30th day (the 12th) instead of the 31st (the 13th) day which is the date on the prescription. If not, would it perhaps be possible to drop the prescription off on the 30th day (the 12th) and return the day after (the 13th, when the script is dated) to pick it up? Please let me know what you conclude. Thank you

   kind regards

     Morgan(Quote)
10. By RalPh, August 14, 2012 @ 9:13 pm

    Next time you are at your doctor’s, ask if perhaps they can do it as a 28 day supply, that way he can say “You got this on 8-14-2012, so counting down 4 tuesdays from there, you can fill it on 9-11-2012.”

    Doing 28 day supplies makes it a set number of 7-day periods that he needs to base his figures on. Otherwise, you need to remind him of differing month lengths when he writes the Rx.

    In Oregon, we can call and get a verbal OK to fill it early as long as its written date is accurate. Some MDs wrongly put the date signed as the date you can get it filled. They should date them all, say, 8-14-2012, with a comment in the directions “Fill on or after 9-11-2012″ or “Fill on of after 10-9-2012″ So, if the doctor dates it correctly like I just explained, if he misfigured the timing, we can call (if we’re not bratty) and ask for a day early refill.

      RalPh(Quote)
11. By Sam, September 14, 2012 @ 1:33 pm

    There are two easy examples of this that occur at my store, one that we have to break the package, and one where the day supply has to cause a DUR reject

    There is a patient who uses 1/2 a tube of testosterone gel each day, and the package is of 30. of course that is a 60 day supply, and of course the insurance only pays for a 30 day. we are forced to break the packaging in order to dispense a 30 day supply, as it is a controlled substance. luckily they come regularly so we end up using the second half on their next script.

    Another is a patient who uses Premarin creme. By the MD directions, it is basically a 28 day supply. No problem, right? Well their insurance only pays for up to a 21 day supply (strange yes i know) so we have to make a tube in as a 21 day supply. That of course causes a DUR rejection that every month we have to call on, and every month the insurance company asks us to ask the doctor to make sure they are ok with a high daily dosage (um its not really that high of a dose its the insurance’s day supply making it a high daily dose). We then have to tell them yes the doctor is okay with the dosage and have to document on the hard copy as well as put a note in the computer saying the doctor was ok with the dosage every single month in order to cover our butts for if (when) they audit us on that prescription.

      Sam(Quote)

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