A Case For An Expanded Role

     What does it mean to you when you hear the phrase “the expanding role of pharmacists?”  Are we capable of pushing our profession forward by legally doing more for patients? 

      I remember at work recently filling a prescription for a patient and having this person’s insurance block the prescription claim.  Three of the most dreaded words on the planet to a pharmacist stared me in the face as I looked at the computer screen- PRIOR AUTHORIZATION REQUIRED. 

     The note that accompanied the third party rejection explained why the drug wasn’t approved.  This person’s insurance required “step therapy.”  This means they needed to try a couple of other medications from a preferred list before the new medication would be approved. 

     It’s a pretty typical rejection to receive if you work in the community pharmacy setting.  But it is still a message I dread passing along to the patient.  You never know how they will react. 

     I explained the situation to the patient.  He calmly replied something like “OK, just let me know when it is fixed.”  He didn’t seem to be bothered by his insurance company’s demands. 

     Contrast this to another patient who handed a prescription to me for a drug that had a generic but was signed DISPENSE AS WRITTEN by the prescriber.  This wasn’t a narrow therapeutic index medication so I called the provider to ask to switch the medication to the generic on behalf of the patient. 

     The substitution was agreed upon by her doctor and I filled the prescription for the generic.  He apparently didn’t mean to sign the DISPENSE AS WRITTEN line.  When the patient arrived to pick up her medication, I told her what had happened. 

     She became angry and said “How dare you question my doctor!”  She quickly followed with “I want the brand name drug like my doctor ordered.” 

     I changed this patient’s prescription back to the brand drug.  She was upset that I had called the doctor even though she takes more than a few other medications that are all generics.  I guess she wanted exactly what her doctor ordered even if the DAW 1 designation was a mistake. 

     My question to you today is this- why is it seemingly OK for an insurance company to question a doctor’s prescribing habits but pharmacists are considered out of line when we do the same?  Does this seem logical to you?

     Insurance companies, through their prior authorization and tiered drug plans, routinely challenge prescribing authority.  Patients have seemingly accepted this role of their insurance company. 

     Contrast that to pharmacists who want to have a medication changed for a patient.  We can call the prescriber and ask for a therapy change and sometimes we are still questioned by the patient even if the therapy change is in their best interests. 

     I think pharmacists shouldn’t have to call a prescriber to change a medication from brand to generic.  Can’t we use our professional judgement and make those kinds of decisions?  Isn’t that a much better option than having an insurance company making therapy recommendations? 

     I’ve often talked about expanding the role of pharmacists.  I think we can make decisions like changing medications from brand to generic or even substituting one antibiotic for another based on a protocol.  We just need the legal authority to do so.

     Yes, these things do already happen in the world of pharmacy.  But I am referring to the widespread legal authority granted to pharmacists to make these kinds of decisions.  That has not yet become the standard by which we practice pharmacy. 

     If an insurance company can block a particular medication based almost solely on their cost analysis, why can’t pharmacists be granted legal authority to do the same based on professional judgement?  Isn’t it time we showed everyone what we can do? 

     We’ve succeeded in other instances when our roles were expanded.  The vaccination program that is commonplace at most community pharmacies is proof of our ability to take on responsibility when it is offered.  We’ve successfully added vaccination services to our practice model without issue. 

     So I’m here today to lobby for letting pharmacists make routine drug therapy changes.   I’m here to argue that we could be doing so much more for our patients.   I’m here to argue for an expanded role.  Isn’t it time?  I think so!

The Redheaded Pharmacist

3 Comments to “A Case For An Expanded Role”

  1. By Blonde Pharmacist, January 4, 2013 @ 8:27 am

    Stopping by… it is time. Overdue. WAY overdue. Nurse practitioners have more of an expanded role with less education.


  2. By LDPlaceboeffect, January 4, 2013 @ 11:13 pm

    State laws with regard to generic substitution have changed and domination of the profession by insurance middlemen have forced the law to bend in a different way. It used to be in Wyoming that a pharmacist filling a prescription with a generic drug, if available was a question only among three people, the pharmacist, the physician and the patient. Then the one with the money to pay came into the picture and told everyone that no money would change hands until ‘they’ had their accountant book had a say in the matter.


  3. By Hirka T'Bawa, January 5, 2013 @ 1:15 am

    I could see another DAW class being allowed, How about a DAW 10, same therapeutic effect in generic vs. the brand drug. Let me substitute that Ciprodex Otic drops that are Prior Auth from an emergency room (that we all know don’t do PA’s), for Ciprofloxicin 0.3% Opth drops, and Dexamethasone 0.1% Opth drops… Same drugs, requires two drop instead of one, and the generic Opth are $3.99 and $9.99 instead of $150+.

    Or, let me change that Crestor 5mg to Simvastatin 20mg, same effect, 1/10 the price…

    Basically… Let me do in the pharmacy what I do when I see my own MD. Let them diagnose my problem, and then I’ll tell that what to prescribe.


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