Dispensing Medications in the Community Pharmacy

Question 1

Primary Role of Pharmacist

Answer 1

to dispense medications safely, accurately, and in accordnce with state and federal laws upon receipt of valid medication orders from licensed providers

Question 2

Prescribers

Answer 2

• Physicians
• dentists
• veterinarians
• nurse practitioners
• physician’s assistants

Question 3

Pharmacy Technician Role

Answer 3

• customer service
• updating patient demographics
• updating insurance information
• entering prescriptions into patient profile
• accurately filling prescription orders
• frees the pharmacist to spend more time resolving medication-related problems and counseling patients about their medications

Question 4

Community Pharmacy Services

Answer 4

• dispensing prescriptions
• compounding noncommercially available medications
• preparing and delivering prescriptions to nontraditional healthcare sites
  
  • nursing homes
  • pesonal care homes
  • prisons
• vaccine administration
• blood presure checks
• laboratory testing for blood glucose and cholesterol levels

Question 5

Front Area

Answer 5

• Community or Retail pharmacy is deivided into two parts. Front area houses:
  
  • OTC drugs
  • dietary supplements
  • medical supplies
  • dietary supplements
  • other merchandise
• May stay open if no pharmacist is on duty
• general public allowed

Question 6

Back Area

Answer 6

• restricted to pharmacy personnel only
• separated from front area by the pharmacy counter
• secured by code or key and off limits to the public including family and friends of pharmacy employees
• When no pharmacist is on duty, this area is closed and locked per state law (metal gate, etc.)

Question 7

Parata Max

Answer 7

an automates system which labels, fills, caps, sorts and stores up to 232 prescriptions

Processes up to 60% of total prescription volume with 100% accuracy for drug and strength

Question 8

Automation

Answer 8

reduces the number of manual fills by pharmacy staff, helping to lower the cost per prescription.

Question 9

Convience

Answer 9

is an important factor when fulfilling the healthcare needs of patients. Several community pharmacies:

• have hours of operation that vary froom 40-168 hours per week
• offer home deliveries
• after-hours availability for working families, shift workers and patients recently discharged
• drive-thru for prescription drop-off and pick-up

Question 10

Customer Service

Answer 10

• becomes extremely important to retaining clientele as patients very often have the option of sending their prescriptions off to large, less expensive, out-of-state, mail-order pharmacy warehouses.

Question 11

Mail-Order Pharmacy

Answer 11

• can fill prescriptions for less cost bc they are atomated and have around-the-clock filling operations
• Many national chain pharmacies offer a mail-order option
• VA (Veterans Administration) also uses several regional centralized warehouses that focus on mail-order drug distribution system
• differ from traditional community pharmacy primarily by sheer workload volume and lack of direct contact with patients
• Some prescription insurance programs encorage patients to use mail-order pharmacies by offering lower co-payments on a 90-day supply of medication

Question 12

Mail-Order Pharmacy Problems

Answer 12

• cost savings benefit may be off-set for many patients by:
  
  • delays in receipt of a needed medication (to the detriment of health)
  • drug wastage
  • minimal counseling offered to the patient by pharmacist contact limited to preprinted sheets of paper or a 1-800 number

Question 13

Community Pharmacy Personnel

Answer 13

• Pharmacist
• Pharmacy Technician

Question 14

Pharmacist Responsabilities

Answer 14

• Responsabilities:
  
  • gathering medical, medication, and allergy histories
  • checking computer warnings about drug interactions
  • verifying, preparing, and dispensing prescriptions
  • counseling patients about their prescribedmedications and OTC drugs and healthcare devices
  • monitoring controlled substancces
  • administering vaccinations
• Pharmacists in independent pharmacies also:
  
  • are involved in managerial tasks of running a business
  • hiring and firing employees
  • evaluating insurance contracts
  • reconciling insurance claims
  • ordering and maintaining inventory

Question 15

Pharmacy Technician Responsabilities

Answer 15

• greeting customers at counter or drive-thru window
• receiving written prescriptions
• ansering the telephone and referring call-in prescriptions or transfers tot he pharmacist
• initiating refills requests initiated by patients in person or by telephone
• clarifying and resolving questions about the prescription (name, directions, etc.) with teh prescriber’s office
• updating patient profiles, including demographics, allergies, and health conditions
• entering or updating billing information for third-party reimbursement
• scanning and entering new prescriptions (or refill requests) into the patient profile
• submitting prescription claims online to insurance providers
• contacting insurance companies to resolve eigibility or prescription processing issues
• counting, reconstituting, packaging, and repackaging products
• preparing and affixing medication container labels for prescriptions
• retrieving and counting drug products from storage in the restricted precription area
• returning stock bottles to their proper storage locations
• distributing labeled medications to the patient aftter final verification by the pharmacist
• storing completed prescriptions fr futre patient pickup
• retrieving medications for patient pickup
• offering medication counseling opportunity for the patient
• accepting payments and co-payments for prescriptions

Question 16

prescription

Answer 16

• Definition: an order of medication for a patient, issued by a phsyician or qualified licensed practitioner for a valid medical condition and then filled by a pharmacist.
• usuallt recorded on a preprinted form bearing the name, address, and telephone and fax numbers of the prescriber
• submitted by hand, phone, fax or electronic transmission (use of hard copies by hand is diminishing being replaced by electronic transmission = e-prescribing

Question 17

Basic Components of Prescription

Answer 17

each prescription must be checked for completness and accuracy:

• DEA number
• NPI number
• Patient Information
• Prescriber Information
• Date
• Rx symbol
• Inscription
• Subscription
• Refill
• Dispense as Written/Brand Name/Generic Substitution
• Signa
• Additional Instructions
• Signature

Question 18

Prescriber Information

Answer 18

Name, address, phone number, NPI and DEA numbers, also state liscence number if required by state of practice

Question 19

DEA number

Answer 19

• Issued by the DEA to a prescriber authorizing them to prescribe controlled substances
• usually hand-written rather than pre-printed on hard prescriptions to avoid forgeries and other security issues

Question 20

NPI number

Answer 20

• National Provider Identifier
• required to file a third-party insurance claim on all noncontrolled prescriptions as well as other reimbursable healthcare services
• any healthcare provider, including a pharmacist, may be assigned and NPI number

Question 21

Patient Information

Answer 21

• Full name (initials are not sufficient), address, phone number, date of birth
• illegible? = re-write the name above the name provided on the prescription, verifying the spelling with the patient at the time the prescription is received.
• ask for secondary phone number if additional information will be needed from the patient making sure it is added to the patient profile

Question 22

date

Answer 22

• of when the physician wrote the prescription should be provided
• date of when the prescription is receive should be typed into the pharmacy computer system
• if no date is written on the prescription, then the date that the prescription is brought into the pharmacy should be recorded as such
• if antibiotic prescription with no date - the pharmacist may want to verify that the patient is under the current care of a physician

Question 23

inscription

Answer 23

• the part of the prescription that lists the medication prescribed, including the strength and amount
• may be listed using brand or generic name

Question 24

subscription

Answer 24

part of the prescription that lists the instructions to the pharmacist about dispensing the medication, including compounding instructions, labeling instructions, refill information, and information about the appropriatness of dispensing drug equivalents

Question 25

refill

Answer 25

an approval by the prescriber to dispense the medication again without requiring a new order.

• if refill section is left blank, then the prescription cannot be refilled.
  
  • no refill - sometimes abbreviated NR, will go on the prescription bottle and also entered into the patient record
• even if refill is indicated as PRN or as needed, unlimited duration is not allowed = most pharmacies and state laws require yearly updated on PRN medications.

Question 26

Signature

Answer 26

• each prescription should be signed in black ink
• should be recognizable by both technician and pharmacist to detect possible forged prescriptions
• electronic signatures may be used on all faxed or electronic prescriptions except for controlled substances
• some states may require 2 signature lines
  
  • Dispense as written
  • substitution permitted
• DAW = dispense as written line is signed then substution of a generic equivilant is not permitted
• Brand necessary = brand name medically necessary is sometimes indicated independent of the signature line. In states that require only one line, if brand name is necessary then it must be indicaed elsewhere on the prescription other than by the signature location. (check box, etc.)

Question 27

DAW2

Answer 27

when a patient asks for brand name in lieu of generic, this request is abbreviated as DAW2 and often results in an increased co-pay

Question 28

Signa

Answer 28

• often shortened to Sig
• part of the prescription that communicates the directions for use.
• this information is transferred from the prescription onto the label that is placed on themedication container for patient use

Question 29

Authenticity of a Prescription

Answer 29

• if any questions of authenticity or completeness the tech should notify the pharmacist immediately
• telephone call to prescriber may be necessary
• In some states, the tech is allowed to verify a prescription, but all changes should be documented on the prescription and in the patient profile, including the name of the nurse who clarified the prescription and initialed by the tech or pharmacist.

Question 30

Types of Prescriptions

Answer 30

• Written Rx
• Medicaid Prescriptions and TRPPs
• Computer entry of Written Prescriptions
• e-Prescriptions
• Telephone/Fax orders
• Prescriptions Not Yet Due
• Transfers In
• Refill Requests
• Partial Fills
• Emergency Fills
• Transfers Out
• Controlled Substances
  *

Question 31

Written Rx

Answer 31

• usually written with many abbreviations
• any misinterpretation of prescription abbreviations could result in a serious medication error
• if any part of the prescription is unclear or undecipherable then the tech must check with the physician before beginning the prescription-filling process
• if pharmacist is unclear on any component then a phone call to the prescribers office is necessary for clarification
• name of the nurse along with the clarification should be entered onto the hard copy of the prescription and into the computerized patient profile

Question 32

Medicaid Prescriptions and TRPPs

Answer 32

• TRPP - tamper resistant prescription pad = specifically designed to prevent copying, erasure, or alteration
• all medicaid prescriptions must be written on TRPPs
• If medicaid patient’s prescription is not written on a TRPP then pharmacy personnel must contact the prescriber’s office to authenticate the order
  
  • date, time, nurse’s name, and initials of pharmacist or technician must be doucmented on the back of the script along with the word “verified”

Question 33

Computer Entry of Written Prescriptions

Answer 33

• must exercise diligent care and effort during the transcription
• critical that the correct patient be selected (many patients have the same or similar names)
• to avoid any confusion, when receiving the prescription the following should be verified:
  
  • name (including correct spelling)
  • DOB
  • address
• critical that the correct medication is chosen from the dropdown menu as many medications have similar names
• any subscription comments written on the script by the prescriber must be included on themedication label

Question 34

e-Prescriptions

Answer 34

• electronically transmitted prescriptions from the prescriber
• common e-script software is Surescripts
  
  • a system that connects prescribers with pharmacies and insurance providers. 95% of community pharmacies can now receive e-scripts from medical offices that utilize Surescripts

Question 35

e-Script Advantages

Answer 35

• speed
• accuracy
• improved billing
• decreased potential for prescription forgeries and medication errors
  
  • eliminating poor subscriber handwriting, misinterpretation of abbreviations, illegible faxes
• e-refills can be automatically sent from pharmacy to the prescriber
• prescriber access to patient pharmacy databases of community pharmacies and insruance providers
• access to insurance eligibility and preferred drug lists of each insurance provider
• For patient:
  
  • increased accuracy
  • decreased wait times
  • depending on the workload at many pharmacies, many times the script can be ready once the patient drives from the dr.’s office to the pharmacy

Question 36

e-scripts and controlled substances

Answer 36

• schedule II controlled substances must remain as a hard copy or printed document with physical signature from a provider licensed with the DEA
• e-prescribing of controlled substances (EPCS) must be approved by each state board of pharmacy before it can be implemented

Question 37

Telephone/Fax Orders

Answer 37

• may be received by the tech but must be referred to the pharmacist for processing
• once the pharmacist transcribes the order into a written script and verifies its accuracy, the tech can enter the information into the computerized patient profile as is done with a new written prescription.
• script is then verified a second time by the pharmacist after tech entry
• Faxed orders are entered into patient profile and verified by the pharmacist before being filled
• Schedule II cannot be faxed and require a hard copy and physical signature

Question 38

Prescriptions Not Yet Due

Answer 38

• a script that does not have to be or canno be filled until a certain date
• is placed on hold for a variety of reasons
  
  • ex. patient may have sufficient meds at home and doesn’t need it filled yet
  • patient may not have cash on hand to pay for all medications
  • lack of insurance coverage until a future date
• the script is typically stored in analphabetized file box or in the computerized patient profile for easy retrieval at a later date
• with the exception of controlled substances, scripts are valid to be filled from one year of the original date written
• most state boards of pharmacy do not permit the storage of schedule II scripts for future use. these medications must be returned to the patient

Question 39

Transfers In

Answer 39

• at patient’s request, most scripts can be legally transferred between pharmacies
• process is easier if the patient presents the transfer pharmscy with the medication vial from the originating pharmacy
• transfer can also be made if the patient provides:
  
  • full name
  • DOB
  • name and phone number of originating pharmacy
  • name of medication to be transferred

Question 40

Processing Transfer In

Answer 40

• according to law in most states, only a licensed pharmacist can transfer or copy a prescription from or to another pharmacy = pharmacist at transfer pharmacy must speak to pharmacist at originating pharmacy
• originating pharmacy must “close” the script to any remaining refills once it is transferred
• there are limits on transfers of controlled drugs
• additional time is needed on a Transfer In:
  
  • make a phone call
  • initiate a hard copy prescription after talking to the originating pharmacist
  • enter the script into the patient profile
  • if a new patient: also time needed to gather demographic, allergy, health and insurance information to complete the pt. profile
• if transfer script has no refills, beyond the year or six-month PRN date then the transferring pharmacy must call the prescribers officer to request a new script before it can be filled.

Question 41

Refill Requests

Answer 41

• easy to do if the patient can supply the prescription number found on the prescription medication label
• most pharmacy software has the capability to record automatic refills when their time is due
• unlike new scripts, refill scripts have already been previously entered and verified by the pharmacist in to the patient profile
• verify that a refill does exist for the requested medication
• forward the request for pharmacist review and approval
• most pharmacies and insurance plans allow medications to be refilled approx. 5 days prior to the next refill date

Question 42

Early Refills

Answer 42

• if refill req. is made too early (prior to 5 day allowance) it will be rejected by the insurance company
• at times a patient may ask for an early refill due to special circumstances (vacation, lost prescription, etc.)
  
  • ins. providers do no cover early refills
  • pharmacy may call ins. provider to get a “one-time” approval for an early refill
  • if prior approval is not received by the ins. provider, the pateitn may need to pay for the script. and send in the receipt for possible reimbursement at a later date

Question 43

No Refills

Answer 43

• uncer certain circumstances, no refills are permitted despite what the medication label indicates
  
  • script that is more than 12 months old
  • script for a controlled substances (schedules III - IV) that was written more than 6 months ago or refilled five times
  • script for controlled drug that has been previously transferred to another pharmacy
• also, scripts written in the ER are commonly prescribed for short-term use with no refills. This protocol should be communicated to the patient so they are aware they need to see their PC for further scripts

Question 44

Partial Fills

Answer 44

• pharmacy may have insufficient inventory to fill or refill a script for the required quantity and will dispense a paratial fill instead for a two- to five-day supply of medication to hold the patient until the new drug inventory is received
• patient is typically billed only for the amount dispensed
• patient must be alerted to the partial fill and advised as to when the remainder of the script can be picked up.

Question 45

Emergency Fills

Answer 45

• a short-term emergency supply of needed medication for chronic conditions such as high blood pressure, diabetes, high cholesterol, or epilepsy
• patients with these scrpts generally have limited refills requireing follow up physician appointments for monitoring and blood work
• most states allow pharmacists to use their best professional judgment to allow a patient a two- to three-day supply of emergency medication to hold them through the gap when a refill authorization will come through
• typically there is no patient charge for a temporary emergency fill of needed medications for a chronic disease
  
  • when the script is renewed by the provider, the amount of medication “loaned” to the patient is commonly subtracted from the refill but the patients insurance will be billed for the complete amount
• emergency refills of controlled substances are seldom permitted except under extremely unusual circumstances

Question 46

Transfers Out

Answer 46

• is a prescription refill in which pharmacy personnel, at the request of the patient, contacts another pharmacy to transfer a prescription
  
  • ex. on vacation in another town
• pharmacist must be notified so that the appropriate medication information and refills are communicated to the “transfer” pharmacy.
  
  • verifies there is a refill
  • controlled substances canno be refilled “early” and can only be transferred one time
  • close prescription once transfer to another pharmacy is complete
• if the medication was already filled at your pharmacy, but not yet dispensed to the patient…it must be retrieved from the storage bins and returned to the inventory
• mediction charges must then be reversed with the insurance provider

Question 47

Controlled Substances

Answer 47

• requires special care becaue of the patients potential to intentionally or unintentionally abuse the drug
• can only be dispensd upon the receipt of a valid prescription writtenfor a valid medical condition
• the date of the original prescription must be entered into the profile rather than the date the prescription was filled
• federal law requires a name and physical address (not post office box) on all prescriptions for controlled substances

Question 48

Schedule II Prescription Requirements

Answer 48

• handwritten or typed
• cannot be e-prescribed, faxed, or phoned in
• most states do allow a nurse, nurse practitioner, or physicians’s assistant to write a script for a schedule II prescription, but it must be signed by the physician
• all signatures should be hand written in black ink
  
  • stamped or electronic is not allowed
• drug, dose, and quantity of schedule II cannot be altered in any way by the nurse, physician, pharmacist, or technician
• Never be refilled - new script is required each time it is dispensed
• if every any doubt, prescriber should be contacted for authenticity
• Some state have time limits on when a schedule II script can be filled
  
  • must be done within 7 days for some states
  • must be done within 72 hours for some states
  • six-month maximum for other states with no time control laws
• Limits on quantity that can be dispensed
  
  • max is 120 units in some states
  • or 30-day supply (usually whichever is less)
  • many pharmacy policies allow only 30-day supply
  • Insurance companies may also impose limits

Question 49

Schedule II Refills

Answer 49

• NONE
• patient may request a “partial fill” due to cost or insufficient inventory at the pharmacy
  
  • if a legit script, a partial fill can be approved, but the remainde of the script is voided.
    
    • meaning the remainder CANNOT be filled at a later date
  • Requireing a new script to fill beyond the partial fill supply.
• causes inconvenience for patients and a provider is allowed to write 2 additional future-dated scripts for the medications to be held until needed
• in most states it is illegal for a pharmacy to hold or retain future dated prescriptions for schedule II drugs, so these future scripts must be retained by the patient

Question 50

Schedule III and IV refille

Answer 50

• may be refilled up to 5 times if allowed by the physician
• they must occur within a 6 month period
• new script reqired after 6 months
• 6 month time frame starts with the date the script was written NOT with the date it was filled
• the 5 refills may include wither full refills or partial refills
• early refill requests must be carefully monitored by the pharmacy
• typically early refills are filled no sooner than 1-2 days before the previous fill is scheduled to run out
• can be transferred only once
• once transferred it must be immediately removed from the storage bin and returned to stock - this prevents the patient from transferring the script to another pharmacy then picking it up from the original pharmacy as well before it is returned to stock

Question 51

Schedule V Refills

Answer 51

• in some states may only be refilled with a physicians authorization
• in some states a limited number of the medication may be dispensed without a prescription
• most of these medications have codeine containing medications
• because of their abuse potential some states have reclassified codeine containing medications to schedule III

Question 52

Controlled Drugs Emergency Dispensing

Answer 52

• schedule II - NO unless:
  
  • state law allows it (most but not all states)
  • have a valid medical reason
  • follows emergency procedure:
    
    • controlled substance administration is to be immediate if the patient is to receive proper treatment
    • pharmacist immediately converts a verba order into writing
    • pharmacist documents the need for the emergency dispensing
    • if the pharmacist does not know the prescriber then good faith efforts are made by the pharmacist to verify that the prescriber is authentic
    • within 7 days (72 hours for some states) the prescriber must deliver a written version of the emergency verbal order to the pharmacy
  • If for hospice patient, a followup hard copy may or may not be required according to state law

Question 53

Controlled Substance Authentication

Answer 53

• carefully reviewes by both tech and pharmacist as this type of script is more likely to be forged or altered by individuals who abuse drugs
• forgeries may be written on stolen or preprinted facsimilies of prescriptions and are often difficult to recognize, especially during a busy pharmacy workday
• telltale signs of poss. forgeries

Question 54

Indicators of Potential Forgeries

Answer 54

• script is altered (ex. change in quantity)
• script pad has been reported missing from local dr office
• script is presented as a clever computerized fax on non-tamper-proof safety paper
• mispellings on the script
• refill indicaed for schedule-II drug
• script from the ER is written for more than #30 count or seven-day supply
• script is cut and pasted from a preprinted, signed prescription
• second or third script is added to a legal script written by a physician
• patient presents a script written for several meds but only wants the narcotic filled
• signed in different hand writing or different ink or is not signed at all
• DEA number is missing
• script is written by an out-of-state physician or physician practicing in an area far from the pharmacy – particularly suspicious if received at night or on the weekend when it would be difficult to verify the script
• individual other than patient drops off the script - pharmacy personnel should require a photo ID and document the person’s infrmation in such an occurance. Also a phone call to the patient may be required to approve the pickup by the person requesting the medication.
• a new patient specifies a brand name narcotic
• a new patient wants to pay for the script with cash, even though they have insurance (doing so avoids a paper trail)

Question 55

Right of Refusal

Answer 55

• a pharmacist has the right to refuse to fill any controlled-substance prescription
  
  • ex. it may not make sense for a narcotic prescription for severe pain to be filled 3 monts following the date it was written
• if a legitimate concern exists that a prescription was not written in good faith, or not for a legitimate medical use, then the pharmacist’s duty is to refuse to fill that prescription from the prescriber and return the script to the patient.
  
  • most pharmacists will make some sort of notation on the prescription to alert another pharmacist to a potential problem with filling the script
• most pharmacies have a “tree calling list” to alert other pharmacies of potential problem prescriptions circulating in the community