Fill At One Pharmacy

I feel that pharmacists do not stress the importance of filling all of a customer's medications at a single pharmacy or at within the same pharmaceutical chain nearly enough. The importance is not my attempt to increase our overall script count, but customers benefit from filling all their medications with the same pharmacy.

With all the different incentives at different pharmacies such as Walmart’s $4 generic list and Rite Aid’s fifteen-minute guarantee, a handful of customers spread their prescriptions all over the place. Just the other day I sold two prescriptions to a customer and she asked us to transfer her remaining three prescriptions to a cheaper pharmacy. I am glad she found a cheaper pharmacy especially in these rough economic times, but she is also doing herself a disservice.

When a customer fills all of their medications at a single pharmacy that customer’s profile reflects all current and past prescriptions. At a single pharmacy the pharmacist can keep tabs on the customer and more importantly have his or her prescription history readily available. With the prescription history the pharmacist checks any new prescriptions against current medications for any sort of drug interaction. Drug interactions may go unnoticed if the customer fills at different pharmacies especially if the customer also visits more than one doctor.

Pharmacy staff also asks about any sort of allergies to any medications for a reason. Allergies are sometimes over looked by some doctors or in some instances, such as a visit to the emergency room, the customer may not remember which drugs he or she is allergic to in the heat of the moment. In these cases the doctors and customer, aware or not, rely on the pharmacist as the last line of defense before the customer receives a potentially life-threatening medication.

My pharmacist has made plenty of calls to doctors’ offices to verify prescriptions and request a change in medication due to interaction. Without all the available information I would hate to imagine what may happen.

Perspective of the Inexperienced

A little while ago I ran in to a girl who had never filled a prescription at a pharmacy before. Trying to remember my outlook on pharmacy before I joined the field over a year and a half ago, I spent some time talking to her just to hear her perspective on pharmacy and what she believed goes on behind the counter.

She surprised me by claiming she does not trust pharmacists. Not that she does not trust a pharmacist will fill a prescription correctly, but that a pharmacist would not be able to guess a diagnosis based on symptoms. No, she believes a pharmacist’s job is to fill the prescriptions written by the doctor and just make sure the correct drug has been dispensed and whether she has any questions.

Based on my experience in the pharmacy I began to believe customers overused the pharmacist and sought consultation as a means to avoid a trip to the doctor. However, I never expected someone would hold pharmacists in such lower regard than medical doctors.

When I inquired further about pharmacy she revealed to me that she does not have a clue what goes on behind the counter. Her best guess was prefilled prescriptions and the pharmacy staff merely had to find the correct medication from the shelf. That guess definitely explained her expectation of a prescription filled in five to ten minutes during rush hour. In fact, her expectation is starting to sound a lot similar to other customer’s expectations when they drop off a prescription.

If only they knew.

Over-Prescribed Antibiotics

Drug resistant bacteria may pose a serious threat in the not too distant future due to the overly prescribed use of antibiotics.

Since the inception of sulfa antibiotics in 1932 and more notably the mass production of penicillin in 1942, the use of antibiotics to treat and prevent bacterial infection has skyrocketed. These antibiotics continually prove to be a valuable asset to fighting illness, but scientists and doctors are becoming increasingly aware of the great potential risk in using the medications.

As Western medicine developed the cultural mentality shifted from preventative medicine and build the immune system to trying to find the next best drug. The repeated use of these drugs actually destroys people’s immune system and when a new strain of drug resistant bacteria arises the immune system becomes helpless and unable to defend itself.

Hospitals suffer from rampant spread of drug resistant bacteria and in an increasing number of cases infections remain unaffected by even our strongest antibiotic created thus far.

In terms of retail pharmacy I fill plenty of antibiotics every day from azithromyacin to amoxicillin and doxycycline among plenty of others. Majority of the antibiotic prescriptions treat customers who suffer minor cold and flu but wish to stop the bug in its track. A handful of customers have antibiotic prescriptions on file with refills so they can call in and have their antibiotic filled at the onset of illness. This self diagnosis does a disservice to the customer as in some cases an infection may not be present and with the constant use of antibiotics the immune system becomes more prone to illness.

However, antibiotics do help in cases where they are necessary and if customers continually take antibiotics doctors and pharmacists must ensure that the customers understand the importance in taking the medication properly to avoid the evolution of drug resistant bacteria. When a customer picks up an antibiotic I must stress above all else, finish the entire duration of the antibiotic. Even if the customer feels markedly improved after a couple of days the bacteria may not have been completely eradicated from the system. The bacteria remaining may then evolve and become resistant to that antibiotic next time around.

Prescription Expiration

Prescriptions expire. The statement can not be repeated enough. Prescriptions expire. Too frequently prescriptions come in to the pharmacy past the expiration date and the pharmacy must turn the prescription down.

The expiration I refer to pertains to the prescription hard copy itself and not the expiration of the dispensed drug.

How long a prescription lasts depends upon the medication prescribed. Prescriptions for medication not listed as a controlled substance last one year from the date written by the doctor. If refills still remain on the prescription they are lost and the pharmacy requires a new script from the doctor – no exceptions.

A common misconception occurs when a doctor writes for PRN (abbreviation for the Latin Pro Re Nata – “as needed”) refills. PRN means the customer may fill the prescription as many times as they feel necessary within the prescription’s expiration.

Scheduled III through V controlled substance prescriptions expire after six months from the date written. Scheduled medications have a shorter expiration date to force customers back in to the office and the prescribed medication may be better monitored.

Scheduled II control substances have the shortest expiration with twenty-one days from the earliest allowed fill date. The earliest allowed filled date may differ from the date written by the doctor. If the doctor sees a patient and decides to prescribe three months worth of the medication, but the patient’s insurance will only cover one month at a time, the doctor may write three different prescriptions to save the patient the copay of visiting the office each month. In these cases the doctor may write an earliest dispense date and no matter what date the doctor wrote the prescription the patient can not fill that prescription before the designated date. If an earliest release date is written the twenty-one day expiration begins on that date and not the date written.

Controlled Substances

State and federal law control the distribution and use of particular substances. The federal law, the Controlled Substances Act (CSA) of1970, originally defined controlled substances. Since 1970, roughly 160 substances have been added, removed, or transferred within categories. (Drug Enforcement Administration, n.d.)  The substances currently listed as controlled fall in to one of five possible categories known as schedules.

Schedule I

• High potential for abuse

• Considered to have no current medical use

• No substance may be prescribed, administered, or dispensed.

• Examples would be marijuana, heroin, and lysergic acid diethylamide (LSD) (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)

Schedule II

• High potential for abuse that may lead to severe mental or physical dependence

• Generally consists of strong narcotics and stimulants

• Examples include morphine, hydromorphone, amphetamine salts (Adderall®), and cocaine (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)

Schedule III

• Less potential for abuse than schedules I or II

• May cause low to moderate physical dependence but possibility of high mental dependence.

• Examples include hydrocodone (Norco®/Vicodin®/Lortab®) less than 15 mg and no more than 90 mg of codeine per dose unit such as Tylenol #3® (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)

Schedule IV

• Low potential for abuse compared to schedule III

• Examples include alprazolam (Xanax®), diazepam (Valium®), and temazepam (Restoril®) (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)

Schedule V

• Lowest potential for abuse

• Include mostly preparations containing limited quantities of certain narcotics

• Examples include Robitussin AC® and Phenergan with Codeine® (Drug Schedule, n.d., Drug Enforcement Administration, n.d.)

Due to the high risk of dependence, customers on long-term use of these medications should be monitored. These medications should not be stopped abruptly and should instead be waned off the medicine.

Customers should check their individual state laws to determine what other regulations may be on controlled medications. Controlled medications may only be transferred from one pharmacy to another unless the two pharmacies are centrally linked (Control Substance e-Rx, n.d.), e.g. a Walgreens in one part of the state can transfer a controlled medication electronically as long as refills remain on the medication and it is not too soon since the previous fill. It may vary between states, but generally controlled medication can not be filled more than two or three days before the previous dose runs out.

References

Commonly Abused Drugs. (n.d.). drugabuse.gov. Retrieved December 1, 2011, from http://www.drugabuse.gov/DrugPages/DrugsofAbuse.html

Control Substance e-Rx FAQs. (n.d.). ncbop.org. Retrieved December 1, 2011, from www.ncbop.org/faqs/Pharmacist/ControlledSubstanceE-RXFAQsApr2010.pdf

Drug Enforcement Administration. (n.d.). DEA Diversion Control - Controlled Substance Schedules. DEA Diversion Control Program :: Welcome ::. Retrieved December 2, 2011, from http://www.deadiversion.usdoj.gov/schedules/index.html

Drug Schedule. (n.d.). Addictions.org - Recovery for Drug or Alcohol Addiction and More. Retrieved December 2, 2011, from http://www.addictions.org/schedules.html

Food and Drug Administration. (2009, June 11). Controlled Substances Act. U S Food and Drug Administration. Retrieved December 2, 2011, from

                  http://www.fda.gov/regulatoryinformation/legislation/ucm148726.htm

Generic Medications

On the flip side of brand name medications exist what are referred to as generic medications. Generic medications often receive a bad reputation due to fears of being much lower in quality and less effective (Stroppler, 2009).

Generics must perform similar to the brand in the body

• The U.S. Food and Drug Administration (FDA) tests generic medications just as vigorously as brand medications (Food and Drug, 2009)

• Generics are required by law to contain the same active ingredients as the brands they copy (Consumer Reports, n.d. Food and Drug, 2009)

• Generics must be administered in to the system exactly the same and as efficiently as the brand names

 Where generics may differ could be something such as the size, shape, or inactive ingredients, e.g. color dye and bonding agents. However, as mentioned before generics must meet certain standards in regards to identity, strength, quality, purity, and potency.

Generic drug costs

Once the patent ends on a brand medication generic manufacturers may produce generic equivalents. Brand manufacturers suffered the steep investment costs innovating the drug so generic manufacturers do not have to go through the same. Without the development cost, generic manufacturers may sell their product at a much lower price (Generic Drugs, n.d.).

With the significantly lower generic medication price some pharmacies offer a deal on generics at low cost. Generic medications that fall under a particular list cost $4 for a thirty-day supply at Walmart, Target, and Kroger. No $4 list, but CVS offers their Health Savings Pass and Walgreens their Prescription Savings Club, each charging $12 for a ninety-day supply on certain generics after an initial annual fee.

Some manufacturers produce both the brand and generic

The brand name Xyzal allergy tablet and its genericLevocetirizine are available as the exact same pill. Similarly, Concerta andits generic Methylphenidate ER are also identical tablets. In fact, ALZA Corporation produces Concerta tablets and supplies them to Watson to be sold as a generic.

References

Reports Best Buy Drugs. (n.d.). Generic Drugs: The Same Medicine for Less Money. Consumer 

             Reports Health. Retrieved November 30, 2011, from 

             www.consumerreports.org/health/resources/pdf/best-buy-drugs/money-saving-

             guides/english/GenericDrugs-FINAL.pdf

Generic Drugs: Information, Cost, and Types. (n.d.). WebMD - Better information. Better health.. 

              Retrieved December 1, 2011, from http://www.webmd.com/a-to-z-guides/questions-

              about-generic-drugs-answered

Generic drug definition. (2004, June 6). MedicineNet. Retrieved November 30, 2011, from 

             www.medterms.com/script/main/art.asp?articlekey=33073

Monson, K., & Schoenstadt, A. (2011, May 17). Generic Concerta. ADHD Home Page. Retrieved 

             December 1, 2011, from http://adhd.emedtv.com/concerta/generic-concerta.html

Monson, K., & Schoenstadt, A. (2011, November 28). Generic Xyzal. Allergies Home Page. 

             Retrieved December 1, 2011, from http://allergies.emedtv.com/xyzal/generic-xyzal.html

Stoppler,M.D., M. (2009, September 28). Generic Drugs, Are They as Good as Brand Name?. 

             MedicineNet. Retrieved December 2, 2011, from 

             www.medicinenet.com/script/main/art.asp?articlekey=46204

Food and Drug Administration. (2009, October 13). Facts and Myths About Generic Drugs. U S 

             Food and Drug Administration Home Page. Retrieved November 30, 2011, from

             http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/

             understandinggenericdrugs/ucm167991.htm

Brand Name Medications

The age old debate that continues to rage to this day and most likely will continue for quite some time: brand vs. generic medication. Brand name medications take the spot light in this post as I go over some of the key talking points concerning brand name.

The Price

Multiple variables factor in to the high price of brand name medications.

• Research and development (Kaiser, 2011)

• Manufacturers try to regain some of the cost that goes in to both successful and unsuccessful drugs

• Advertising and marketing (Kaiser, 2011)

• Manufacturers invest heavily in to advertising new and expensive drugs to doctors and patients

• Patent protection (Kaiser, 2011)

• New medications may be patented for up to twenty years giving exclusive right to the manufacturers to sell the drug.

In a perfect example, Pfizer has moved to extremes to protect one of their most profitable drugs, Lipitor. Pfizer will pump millions of dollars in to marketing Lipitor further in an attempt to undermine the recently released generic.

But the brand is safer and better than generic right?

Not necessarily. Have you tried looking for brand name Tylenol®, Benadryl®, Motrin®, Rolaids®, Simply Sleep®, or St. Joseph’s® aspirin on the shelves in the past year? The mentioned brand names have been hard to find because McNeil PPC, Inc. recalled the medications and pulled them off theshelves.

McNeil PPC, Inc. created a site to explain and provide affected lots.

However, do not allow the fault of one manufacturer completely discredit the rest. I mention this particular manufacturer simply to prove the point that just because you buy brand does not mean you are buying the best quality.

References

Associated Press. (2010, January 21). Tylenol recall expanded to Motrin, Benadryl, more. News, Travel, Weather, Entertainment, Sports, Technology, U.S. & World - USATODAY.com. Retrieved December 1, 2011, from http://www.usatoday.com/money/industries/health/2010-01-15-tylenol-recall-expands_N.htm

DeNoon, D. (2010, January 15). Tylenol, Motrin, Benadryl, Aspirin, Rolaids Recall. WebMD - Better information. Better health.. Retrieved December 2, 2011, from http://www.webmd.com/pain-management/news/20100115/tylenol-motrin-benedryl-rolaids-aspirin-recall

Johnson, L. A., & Press, A. (2011, November 30). Lipitor will be far cheaper as patent expires. News, Travel, Weather, Entertainment, Sports, Technology, U.S. & World. Retrieved December 1, 2011, from http://www.usatoday.com/money/industries/health/treatments/story/2011-11-29/Pfizer-maneuvers-to-protect-Lipitor-from-generics/51475288/1

McNeil PPC, Inc.. (2010, October 8). MCNEIL PRODUCT RECALL. MCNEIL PRODUCT RECALL. Retrieved December 1, 2011, from http://www.mcneilproductrecall.com/

The Kaiser Family Foundation. (February 2010). Prescription Drug Costs: Issue Modules, Background 

                 Brief - KaiserEDU.org, Health Policy Education from the Henry J. Kaiser Family Foundation. 

                 KaiserEDU.org. Retrieved December 1, 2011, from http://www.kaiseredu.org/Issue-

                 Modules/Prescription-Drug-Costs/Background-Brief.aspx

The Prescription Filling Process

Before proceeding to other topics I thought it necessary to actually explain the process of filling a prescription in the pharmacy. While different pharmacies may differ slightly the general process is the same.

     1.   Customer drops off the prescription at the pharmacy

     2.   Pharmacy technician should ask if filled at the pharmacy before

     3.   If not the customer’s personal information needs to be entered in to the computer

• Name
• Date of birth
• Address
• Phone number
• Any allergies to medications
• Insurance information

     4.   If so the technician will proceed to inspect the prescription to verify crucial information

• Customer’s name and spelling
• Customer’s date of birth
• Date doctor wrote the prescription
• Name of medication
• Medication strength
• Proper and legible directions (Sig – from Latin word Signa meaning “write”)
• Quantity of medication
• Number of refills prescribed
• Doctor’s Drug Enforcement Agency (DEA) number
• Doctor’s signature
• Prescription’s security feature (differs from script to script)

     5.   Pharmacy technician types prescription in to system to be filled

     6.   Prescription joins queue to be filled in proper order based on time entered

     7.   Generally people who wait for the prescription in store gain priority

     8.   Pharmacy technician prints out label

     9.   Drug stock bottle pulled from shelf

    10.  National Drug Code (NDC) on stock bottle compared to NDC on label to ensure proper drug
           has been pulled

    11.  Pharmacy technician counts (in intervals of five) proper dispensed quantity

    12.  Some drugs may be double counted to ensure proper dispensed quantity, e.g. controlled
           medications

    13.  Counted medication dispensed in to vial which is then capped and labeled

    14.  Prescription vial and label passed to pharmacist to be verified

    15.  Pharmacist verifies the prescription has been properly inputted against a copy of the
           prescription hard copy

    16.  If no mistakes were made the prescription is then bagged, ready to be sold

During the entire process the pharmacist and technicians must field phone calls, answer questions, and assist other customers.

Mail Order

Working in a brick and mortar pharmacy I occasionally interact with a customer who participates in mail order. Mail order means instead of picking up prescriptions at a brick and mortar location the customer receives his or her prescriptions directly in the mail. Admittedly mail order is out of my range of expertise, yet I felt obligated to address mail order as increasing numbers of customers interact with mail order pharmacies.

To address my lack of expertise I ventured out and asked a handful of questions about the process to a gentleman who was polite enough to provide insight in to his mail order experience.

This particular person has been using mail order for the past three years through his insurance. Initially the insurance offered the option of either mail order or the ability to fill at a brick and mortar pharmacy. However, his insurance no longer allows him the ability to fill at a brick and mortar store under his coverage and now requires him to use mail order.

The Process

• He must either have his doctor call in his prescriptions directly to the service or he may mail a hard copy of the prescription.

• Pending any problems the prescription arrives directly in his mailbox within a few days.

Once a prescription has been established for something such as a maintenance medication such as blood pressure he can go online and request the next refill or sign up to have the medication automatically filled and sent to him without prior consent. If the prescription has no remaining refills the mail order service will request a new prescription from the doctor and fill once the service receives the new prescription.

While the service provides the convenience of not physically going to a brick and mortar store shortfalls still remain. For example, mail order service cannot provide quick enough service to fill emergency prescriptions. Emergency scripts must be filled promptly and in the case of the person I spoke with his insurance will not cover any scripts filled at a brick and mortar location. Therefore, if he wants the prescription immediately he must have it filled at a brick and mortar pharmacy and pay for the entire cost of the drug out of pocket with no reimbursement from his insurance.

A Pharmacist's Perspective

A pharmacist was gracious enough to sit down with me during his little free time and answer a few questions about what he thinks about retail pharmacy. The pharmacist asked that I only record an audio file for privacy purposes. He answers questions from how the retail field has changed to his personal frustrations in the field. The audio is transcribed below.

Me: All right, I’ve gotten the chance here to sit down with a pharmacist in a retail store. I just wanted to begin by thanking you for coming out and spending some time with me. I know you have a busy work schedule and all.

Pharmacist: Oh it’s my pleasure.

Me: Let’s just get right down to business. Just to begin, how long have you been a pharmacist?

Pharmacist: I’ve been a pharmacist for fourteen years.

Me: Fourteen years and retail the entire time?

Pharmacist: Yes

Me: How do you feel over the fourteen years has it remained relatively the same, the environment? Or do you feel the retail has definitely changed?

Pharmacist: Oh most definitely it has changed a lot. Obviously, the technology has changed. The way how the pharmacy will run and the customer. For instance, when I first came out from pharmacy school as far as insurance base, maybe forty to sixty percent. Let’s say about forty percent are insurance and the other sixty percent are cash. But now, as far as pretty much eighty to ninety percent are insurance and the remainder are cash customers.

Now as far as technology wise, when we got out of pharmacy school we still had the typewriter as a backup, obviously. We had the dot matrix printer where we had to line the label correctly otherwise it would print out and it’s not correct and you would have to redo it.

Me: Now do you feel, I know technology has helped as well, but do you think technology has also kind of hindered? Now how do you feel, say, when the system goes down. Before, were you able the fill a prescription without any kind of computer if you were using the typewriters as back up? But now do you feel you have as secure a back up system as you had before? Or is it at a kind of a stand still?

Pharmacist: I think it’s both. I mean obviously with the technology that we have now we can do a lot more prescriptions in a given time compared to back then. But obviously, with technologies you base on that and if it goes down you’re pretty much hopeless now.

Me: Now how do you feel about the customer base overall? Do you feel they are well educated in the way pharmacy works? Or do you feel that a lot of customers may be unaware or simply want their drugs?

Pharmacist: I think as far as medicine wise people are more knowledgeable now than back then. Obviously, back then we didn’t have the Internet. You couldn’t Google a disease state or medication. We have a real big, big, big book where we look up everything from drugs to dosage to interaction. Patients could buy a book and refer to that. But now as far as knowledge of medicine patients definitely have an advantage now as compared to back then.

Me: How about in terms of healthcare? How do you feel about patients knowledgeable about their insurance? Do you feel there’s any kind of frustration between common knowledge, or feel the customer should be more aware of their coverage before walking in to the pharmacy? Do you feel that they rely on the pharmacy a little too much to take care of their health coverage?

Pharmacist: Yes. I would like the patient to be more responsible basically about their own insurance. But I think that most the time that because of the deductible the health care companies are setting there is frustration. I mean, obviously they know what their deductibles are. But obviously when they come to you and you tell them their prescription is $145 for eye drops or something like that, it’s just shocking to them. I think it’s basically a reaction to that. I think because of the Internet and the way the insurance is structured they are informed about their health care, yes.

Me: Moving along is there any kind of frustration or main problem that you see on a daily basis? If you could just have a sign out to change a couple things in the pharmacy, is there anything that just irks you?

Pharmacist: Probably time and more help. You know, in a retail setting, you do a lot more prescriptions, at my store anyway.  And you wish you had more time to give to patients on a more individual basis - consultations or talk to them in general about their well-being.

Me: You mentioned consultations. How do you feel about consultations? Do you feel like customers are utilizing the option? Do feel like it should be there or do you feel like it is taking away from your job? Are you too busy for consultations?

Pharmacist: Yes. I think consultations are great when you have the time, but obviously as far as accessibility as being the pharmacist where you are accessible to the customer 24/7. You can become a little more frustrated because there are other things you want to do at the same time you want speak to them and that can be a conflict of interest.

Me: You said with the frustration of time and with the pure quantity that you are filling prescriptions, do you feel the corporations are putting too much pressure on the pharmacists to put out for sheer numbers and you’re losing a lot of quality one on one time with the customers?

Pharmacist: Yes, most definitely. You would like to fill about 20 prescriptions per hour, but that is not the case. You are doing about 50 to 60 at least an hour and it’s not just filling prescriptions. There are other things as a pharmacist in the retail setting you definitely have to multitask.

You have to check the voicemail. You have to take time to counsel the patient, even answer a simple question on the phone, or when a customer walks in about over the counter products, or insurance. They will call you and ask you about the insurance, the copay, things like that.

Me: Just to finish up I have to ask: Are you still loving it? Do you recommend it? Are you still everything about it?

Pharmacist: I think to work in a retail setting you have to be a special animal. You know, not everyone is born to be a retail pharmacist. But as for me, I love it and I think that’s what I’m going to continue to do.

Me: Okay, thank you for your time. I appreciate it.

The PharmD

During a visit to the pharmacy a customer may not consider the credentials of his or her pharmacist. The requirements for becoming a pharmacist changed radically in the past twenty years. Now, a pharmacist is required to have a Doctor of Pharmacy degree or more casually known as the PharmD.

The process to become a licensed pharmacist in the United States generally looks as such:

• 2-4 years of undergraduate study including study in mathematics and natural science

• Take the Pharmacy College Admission Test (PCAT)

• Apply for accredited university or school of pharmacy

• Approximately 4 years to complete PharmD

• Pass both the North American Pharmacist Licensure Exam (NAPLEX) and appropriate pharmacy law exam

The Association of Colleges of Pharmacy (AACP) declared that a PharmD would be the new first-professional degree. The PharmD typically takes four years to complete after a prior two to four years in undergraduate study. On top of the undergraduate study most if not all pharmacy schools in the United States require potential pharmacists to take the PCAT. The score on the PCAT along with the student’s performance during undergraduate study determines entrance in to the prospective pharmacy school.

However, once a student completes pharmacy school and obtains his or her PharmD the process is still not complete. Once awarded the PharmD the person must then pass both the NAPLEX and proper pharmacy law exam according to the state.

Pharmacists licensed before the PharmD was required are not required to go back to school for the PharmD. These pharmacists share the same license as the incoming pharmacists who acquired the PharmD and therefore equally qualified. However, only pharmacists who acquired the PharmD may use the prefix “Dr.”.

Drive-Thru Etiquette

While working in the handful of pharmacies I have covered shifts in beyond my own store, I have yet to meet a pharmacy staff member that likes the drive-thru. The drive-thru ends up rushed, forces priority to the people in the drive-thru to get them in and out, problems must be hastily corrected to provide timely service, and increased stress is placed upon the staff to serve both the customer who expects to come and go in the drive-thru and the customers in the store. However, drive-thrus will remain as long as big chain retails have pharmacies.

Drive-thru lanes have a time and place for customers and they are not always the appropriate option depending on the situation. Sadly, not all customers respect drive-thru etiquette and their problems not only prolong their stay at the pharmacy, but also the line of customers behind them. Certain problems can be avoided while others may require more time than the drive-thru allows.

An issue with the prescription fill

• Be willing to come inside the pharmacy or go around. Inside the pharmacy the pharmacist can take more time to explain the situation to the customer and how to solve the prescription problem. Sometimes the prescription simply has not been filled yet, but if we must fill four medications that will take time and the rest of the customers in the drive-thru line do not want to wait as well.

If the doctor was supposed to call/fax a prescription ahead of time

• Call the pharmacy ahead of time and make sure the prescription is already filled. Prescriptions are filled in the order they are received. However, prescriptions brought in to the pharmacy and waited on by other customers take priority. Though your doctor may have called the prescription in three hours ago it may not have been filled yet because the pharmacy has not had time. A call ahead will ensure the prescription has been received and will be placed higher on the list to be filled.

Most pharmacies with a second drive-thru lane is drop off only

• The air powered chute cannot handle heavy prescriptions and may get stuck. While some of the lighter prescriptions may be able to go through the chute, the pharmacy does not wish to risk having a prescription stuck leaving the customer without medication and the chute broken for future customers.

Do not expect to wait in the drive-thru

• Refills may be requested in the drive-thru, however customers cannot wait in the drive-thru for the prescription to be filled. Pharmacy drive-thrus are like fast food drive-thru's. The fast food place may ask you to pull around while the food cooks, pharmacy is no different.

The drive-thru is not for shopping

• The pharmacy staff member may be willing to grab an over the counter (OTC) medication to purchase with the prescription, but do not expect them to also grab you a gallon of milk and a handful of other items.

Other customers are waiting inside

• The pharmacy is well aware of the customers in the drive-thru. However, often other customers are also in the store that must be attended to as well. Be patient, a pharmacy staff member will be with you as quickly as possible.

Prior Authorizations

Prescription prior authorization (PA), the insurance rejection that forces me to cringe every time I read it. Prior authorizations are requested by the insurance company and not the pharmacy. However, the pharmacy usually ends up catching the flak as agitated customers stand confused as to why they cannot pick up their prescription that day.

Here's the scenario:

Me: "Your insurance is rejecting the claim for the prescription. They want a prior authorization from the doctor before they are willing to cover the medication."
Customer: "What? But I need my medication."
Me: "I understand and we are willing to fill your medication, but the doctor needs to complete the prior authorization with the insurance before the insurance is willing to cover it if they choose to authorize the coverage."
Customer: "You're holding the prescription in your hand! The doctor must think I need to be on the medication if he wrote the prescription. I need that prescription filled today."

When faced with a prior authorization the pharmacy cannot do anything to force the insurance to cover the medication. The pharmacy will be more than happy to fill the medication, however, if the customer chooses to pick up the medication prior to the authorization the customer must pay for the medication cost in full, or "out of pocket." Too frequently the cost of the medication is insanely high and the customer leaves without the medication. If the customer chooses to pay for the medication out of pocket and the insurance company declines to cover the medication after review, the customer remains stuck with the full cost of the medication which cannot be returned.

The Solution

Though prior authorizations cannot be avoided if the drug is not on the customer's insurance formulary, customers can ease the process by walking in to the pharmacy prepared. First, the customer should understand the basic process of a prior authorization.

1. The prescribing doctor must contact the customer's insurance company via fax or phone and explain why the customer must be on the prescribed medication.
2. The insurance company evaluates the prescription and current medications to determine whether or not the company chooses to cover the medication
3. The insurance company contacts the doctor to inform whether the authorization has been approved or denied.
4. If the authorization has been approved the pharmacy may now resubmit a claim and charge the customer the proper copay according to coverage.

Many insurance companies offer information on what triggers a prior authorization and the forms required by the doctors on their websites. These forms can be printed prior to the doctor's appointment if the customer already knows that the doctor may prescribe a medication not on their formulary. That way the doctor can initiate the authorization before the customer even walks into the pharmacy. Understand, however, that most authorizations take a minimum of 24 hours and more likely in the 48-72 hour range before approval or denial.

Some Major Insurance Prior Authorization Sites

• Caremark
• Medco
• Blue Cross/Blue Shield of CA
• Humana
• Cigna (PDF)
• Tricare
  

Prescription and Medical Insurance Are Different

When customers bring their prescriptions to the pharmacy, I ask if they have insurance. Too many times the customer produces an insurance card, but it is their medical insurance card and that company does not cover the customer's prescription costs. Here is the scenario that too frequently plays out:


Me: "Do you have insurance?"
Customer: "Yes."
Me: "May I see your insurance card?"
*Customer hands me his insurance card that I proceed to look over*
Me: "Did they provide you with another card for your prescription coverage? This only covers your medical costs."
Customer: "No. That's the only card they sent me."


At this point I can do nothing for the customer other than to suggest calling their health benefits manager and find out which insurance company covers their prescriptions. The customer never enjoys hearing this and often it leads to yelling or statements such as, "<Different pharmacy> has always been able use this card!" No, the other pharmacy had no use of that medical card and they must have found the customer's prescription information through some other means.

The Solution
The best way to avoid this situation is through basic insurance card education. Insured individuals should always carry their insurance cards with them, but before cramming it into the wallet take a minute to read the information on the card. Generally the information will be presented in one of three ways.

Cigna Insurance Card

If the insurance company covers prescription costs along with the medical coverage the letters Rx will be printed somewhere on the card.

United Healthcare Insurance Card

 






Sometimes the insurance company does not cover prescriptions but prints the information of the company that does on the same card.

Caremark Insurance Card

Other times a different company handles the prescription coverage and in turn provides their own prescription card.






 


 Regardless of the insurance company, the pharmacy is looking for four pieces of information.

• RxBin - the Bank Identification Number routes a claim towards the right insurance
• RxPCN - the Processor Control Number further narrows the claim to the specific insurance
• ID - the member's designated identification number
• RxGrp - the prescription group number denotes which group plan the member ID falls under

With those four numbers the pharmacy can properly submit a claim to the right insurance. If the insurance card does not have Rx or RxBin somewhere on the card then the card most likely is not their prescription card and the customer needs to hunt that information down.

First the Author

Welcome to Understand Pharmacy!
I wish I could disclose my personal information to you, but under the Health Insurance Portability and Accountability Act (HIPAA) I am not allowed to reveal my identity, who I work for, or any specific information pertaining to my customers. I will, however, say that I have worked as a pharmacy technician for a major chain pharmacy for over a year and continue to work full time. As a technician I continually learn the ins and outs of pharmacy which surprisingly has to do with much more than just filling a bottle with pills. Through the filling process, a handful of obstacles must be overcome from the point a customer drops off their prescription to point of sale. Too many obstacles result from a breakdown in communication or poor understanding and pharmacy education.

I do not aim to merely rant on this blog, but instead relay the all too common experiences that occur in the pharmacy and provide a means to alleviate the situation. These experiences will be provided as an example foundation to introduce a problem and provide a solution to the problem. Through this problem/solution scenario I aim to not only provide insights to what actually goes on behind the counter, but also improve future experiences of both the customers and pharmacy staff.

As a further disclaimer I do not aim to belittle any person or lay blame on either party involved in examples. My information will be based upon actual occurrences in the pharmacy and any further research necessary to provide a means to avoid such situations.

Enjoy.