Happy New Year!

For those of us who work today, keep one thing in mind. Today is the last day you get to hear "Just fill everything I have a refill on that's in my profile whether or not I've taken it or am still on it from last January" for the next year.
For tonight ushers in a new beginning. A new set of favorite quotes, if you will, starting tomorrow.
"What do you mean my insurance changed?"
"What do you mean I have a deductible?"
"What do you mean my copays went up a whole dollar?"
"Why don't you accept my insurance anymore?" (We do, but just because your copays went up, doesn't mean we don't accept it...)
"I didn't pay that much here last month!"
"Why isn't my prescription covered here anymore? It was last year!"
"It was covered when I went to ABC pharmacy last year."
"No, they didn't send me a new card."
"A new card? Oh. It looked the same so I left it on my kitchen table."

Customers may forget what happened a year ago when the insurance clocks reset. Pharmacists never do. Patients may hate the hassle of dealing with their one insurance. Pharmacists have to deal with thousands of different ones, weekly. We are all in the same boat and all have a common goal-figuring it out so we know what to expect the next time we see this particular card and figuring it out so we can explain it to you so you understand it going forward. It's what we do. Patients receive Explanations of Benefits usually around December. Few read them. Fewer understand them. Simply put: New Year, New Rules. Everything changes January 1st.
Remember the "Warning-Peak Times Ahead" Post from last week? This is where we need the digital board that reminds everyone "New Insurances Ahead. Expect Delays".

Good Luck this holiday and Happy New Year!

Different Rules

Pharmacy...The scene...Patients line up outside the pharmacy gates before we open. Cars queue up at the drive-thru before we open. It's anticipation. Better make sure we open exactly at 9am. (They watch us with a "we see you in there so just help me now!" look in their vacuous stares.

Doctors...The scene...Patients wait outside before they open. Maybe they open the doors at 8:05. Maybe later. Patients are okay with that. They know they have a scheduled appointment time and lots of magazines and TV shows to watch until someone decides, rather ambiguously, to call them back much later than that scheduled time. Lunchtime is usually from 12-1pm. Phones go off at...maybe 11:45 today. Maybe 11:52. Who knows? People are okay with that. Phones come back on at 1pm? Never. 1:07? 1:11? 1:19? Who knows. We get the answering service who is mad at us for calling and they tell us "they should be back. But try later." Patients call us and tell us to call. Right. I have the same number to reach them that you do.

Pharmacists...Lunchtime arrives. For us, that's just the hours between 12 and 4pm. No significance other than we can't reach doctors from 11-something to 1-something. Grab a handful of Cheetos and wipe my hands on my off-white smock. Oops. Chug a Mountain Dew. Keep trying to decipher the e-scripts and voicemails I got after your doctor shut off their phones for lunch.

Doctors...4-5pm. Switch off phones at some point before they say they are closed. Hurriedly leave a dozen voicemail messages in a speed contest against the other office lady sitting next to you so the pharmacy can't possibly call you back on them. Patients know they are closed and don't rush the staff for last minute appointments as the staff is walking out the door. Which is good because the doctor left hours ago, but the staff is just finishing the calls.

Pharmacists...5-9pm. Explain to customers the doctor switched off their phones early. Patients say "that's okay. They work long days. But you bastards need to give me my meds now. I'll be waiting." After a 12 hour day at 9pm we lock the gates, close the door and start to our cars. Multiple people run up to us and coerce us to open the pharmacy because they have to have their stuff tonight because they've been out for 6 days, are going to now die without them, and they've been waiting to be picked up for 8 days even though they were written 3 months ago.

Pharmacies have posted open and close times. Doctors use some rather amorphous scheduling when they decide to open and close and switch their phones to the answering service.
Over generalized? Sure. True for many offices with which we deal? Definitely. Every day in the life of your pharmacist? Absolutely.

Your dog ate what?

I don't know where to store this. I imagine if I ever had one, I'd keep it in a nightstand like a lot of people. It would probably occupy the same space as the other stuff used for those special occasions. I'd try to make sure that access was quite limited as well. I'd probably make sure to put it away in its safe place when done so it doesn't get in the wrong hands. Still, I am always surprised when I get questions about how to replace one. Or how quickly can it be replaced? Then I'm surprised that people think this is their only option. I can think of at least 8 other options, but that's just me. Seriously, how do people let these fall into the wrong hands?

Over the years I have heard:
My dog ate my diaphragm.
My kid chewed my diaphragm.
My son wore it as a yarmulke.

Okay. These examples likely mean you left it out. I'm sure the kids could riffle through your drawers but by the time you have kids, you should probably move the other stuff in that drawer as well.

Everything's Free

Get your FREE stuff at the pharmacy.
People love to get free shit. Always. Doesn't matter if they need it, could use it, or even know what it is, as long as it's FREE, they gotta have it. If everyone else is going to get free shit, sign me up for mine too or life just isn't fair.
New stores open and give out free samples as enticements. It's usually coffee or ice cream or baked goods. I've never thought of going to a pharmacy for free shit just because it's free.
"Free Antibiotics!" "Free Diabetes medications!" advertised all over the country.
"Free Advair (*with prescription)" and many other manufacturer gimmicks abound, all with that "*" restriction.

Look, the rules still apply. You still need a prescription for anything you normally need a prescription to receive. You can't get a FREE oil change if you don't have a car. I am still amazed, though I really shouldn't be, by the number of people who walk in to the store, or lazily glide into the drive-thru, and expect us to just hand them free shit.
Lazy Douche: "It says free diabetes medications?"
Me: Yes. You can read. And?
LD: I want some of it.
Me: Do you have a prescription?
LD: Doesn't say nothing about that.
Me: It does, actually. And I retract my first statement. Do you have diabetes?
LD: No. It just says "free" and I want some while I can get it.

I wonder if people are shopping online for Christmas presents and when they see "Free Shipping", I wonder if they just order that. Without buying anything else?

Customer: Now how do I just order the free shipping? That'll be just perfect to put in her stocking. I'll also sign her up for a free estimate on new windows. Best Christmas yet if I can get her the Metformins too.

Grammar Lesson-Pronouns

Pronoun: Pronouns are used in place of a noun that has already been mentioned or that is already known, often to avoid repeating the noun.
Focus on the "already been mentioned" part of that...
While it is quite common for people to abuse the English language, the biggest issue I have, today anyway, is the mysterious pronoun people. There is a great song by Jem called "They". In it, she asks "Who are they? Where are they?" Did you ever wonder who they really are? Especially when patients come in with all of their "they" stories:

1.They told me it would be here.
2.She said she sent it.
3.He said it was ready.
4.They told me it was only $4.
5.They said I could go to any pharmacy.
6.She told me to come here and pick it up.
7.She said they negotiated the price down.

Again, I ask, who are "they, he, she, and it"?

Let's try:
1.My doctor said my prescription would be here.
2.The nurse at the office this morning said she sent my prescription electronically.
3.I spoke with the tech this morning and he told me my prescription was ready.
4.My insurance told me I could go to any pharmacy.
5.The doctor's office told me this medication was on your $4 list.
6.My wife just told me I was supposed to come here to pick up her prescription.
7.(I still have no idea what the last guy was talking about with a negotiated price.)

It's a little like jumping into the middle of a movie, with the characters and plot already established, and trying to figure out why he hates her and they are trying to chase after them while they are also being tracked by them for seeing it happen while she still loves him but he's now with her and it's going to happen again if someone doesn't stop them from doing something, except the TV isn't working so you can only hear the movie, and the movie keeps starting at different points all day long and the characters keep changing and you can't mute or rewind it and it doesn't end until you get in your car and it's a cliffhanger that you know will continue tomorrow like the old Saturday matinees except no one has figured out how to it's going to end. Please make it stop. 

Can you teach a Doctor?

Doctors. What are we going to do with them? We need them, but can they be taught? I believe they can be trained, but they really need reprogrammed. Examples: (Yes by doctors, not just their staff.)
This will be ready when you get to the pharmacy.
It's pretty cheap. Usually under $10.
You don't need a new prescription if you have refills left. Just triple your dose and tell the pharmacy I said it's OK and they'll just fill it.

1. Your doctor does not work in my pharmacy. Never has.
2. I don't work in his office. Never have.

I don't tell him how to run his office, he shouldn't tell you what I do in my pharmacy.
No matter how many times we call offices and tell patients to remind their doctors, the doctors will still send patients in for refills on medications where they changed the dose/strength/frequency and the patient is now too soon. Do they not remember the point of a prescription is to tell me what to tell the patient? Do doctors not know we bill insurances? Do they not know how to do math? (No, hence all the q.s. quantities.) Do they not know a new prescription is required every time they give you something new? Like new directions? New strength?
You're right. I said they don't work in my pharmacy. How could they know this? Perhaps taught in school? Prescription writing 101? (Obviously taught with penmanship-they skipped those classes.) Perhaps experience? Pharmacists call and request a new prescription because he changed something. Pharmacists tell the doctor we need to know the correct information so we can perform our jobs too. Pharmacists call and call and call. I guess the answer to my somewhat rhetorical question is, no?

Either Way...

Damned if you do, damned if you don't...This is an either/or post. Pick one side.
Patients receive too many phone calls.
Patients receive too few phone calls.
Pharmacies make too many phone calls.
Pharmacies make too few phone calls.

So we call:
Either/Or Patient: Why did you call me?
Me: You have no refills on your prescription. We were calling to let you know so you could save a trip until we hear from your doctor and that you may want to call him yourself.
EOP: I know that. That's why I called. So you could fax him. You're stupid.

So we don't call...
EOP: Why didn't you call me and tell me I had no refills?
Me: True, there were no refills. We faxed your doctor and were waiting for a call back. Your bottle says no refills. The machine told you no refills and we would fax the doctor.
EOP: Now I wasted a trip. You're stupid.

So we call...
EOP: Why did you call me?
Me: Because your refill is due. The automated system wanted to let you know it was ready to be filled and to ask if you wanted us to get it ready.
EOP: No it's not. I still have plenty of pills left. You're stupid.

So we don't call...
EOP: Why didn't you call to tell me my bottle was empty? I've been out for over a week now waiting for your phone call. You're stupid.

So we call...
EOP: Why did you call me?
Me: The computer called to let you know your prescription has been down here waiting to be picked up for 3 days, 7 days, 9 days, 10 days, whatever...
EOP: She didn't tell me what it was. I don't know why the doctor called that in. I don't need it. I don't take it anymore. You people just fill anything, huh? You're stupid.

So we don't call...
EOP: Where is my medication? It was supposed to be here last week.
Me: It was. Your doctor called it in but you never came in for it so we put it back.
EOP: Why didn't anyone call me? I obviously need it. My doctor sent it here didn't he? Must mean he wants me to have it then. Boy, you're stupid.

Others:
Why do you people keep calling me? If I needed it, I'd call it in myself. This is harassment. I'm going to sue you and go somewhere else.
Why don't you people call and tell me when I'm supposed to take my medication. Isn't that your job?
Why didn't you call to tell me my insurance changed? Now I am here and I left the card sitting on my kitchen table. It's all your stupid fault.
Why did you call me to tell me my insurance changed. I know that. I have the card right here.

I could go on...

Little (Pharmacy) Drummer Boy

Come, they told me, to your pharmacy.
E-Scripts would be ready, or so they told me.
I do not understand what's taking so long.
I just left their office and now I am here, waiting for you, give me my drugs.

Sir, sit down right there, we'll have it ready, when it is done.

Have you been here? we asked him knowing.
I have before, he said, his temper growing.
Insurance cards I need? Oh what do you mean?
They told me four dollars and one should be free, aren't your drugs free, won't you help me?

Prior Auth we need, your doctor we'll call, will you wait?

Office was called, and now we can fill
The meds for you kind sir, staring at me still.
We did our best for you, thankful you should be.
Home to your wife now run, for holiday fun, my job here's done, thanks now I'm done.

Then he smiled at me, the nice little man, Cialis in hand.

Insurance Cards-The Bad

The flip side to patients not having their insurance cards is patients having too many insurance cards. Please, at some point, go through your billfold and chuck the old cards. Seriously. You only need to keep the most current card. If they issue you a new card, like most insurances do at the beginning of the year, it is meant to replace the old one, the now obsolete one. To replace means to remove the old one, throw it away, and place the new one in its predecessor's warm comfy home.
How many do we carry now just for ourselves? We have a medical card, prescription card, dental card, vision card, then the same ones for the spouse and each of the children. Throw in a few discount cards just for fun while you're at it. Keep the cards for the last 5 years and you could play Pinochle with them. The worst part is when they dump a casino's daily supply of cards on your counter and say "here you go. you figure out which is correct". How about "NO"? I am not employed by the show "Hoarders" to help you organize your wallet. It's your insurance. You figure it out.
It's December. New cards are arriving this month. Don't ignore them because they are not Christmas cards. Take this opportunity to clean house. If a new card arrives, hold it, caress it, love it and squeeze it and call it George. But please put it in your wallet only after clearing out the debris from the Clinton administration. This way, when we ask if you have new insurance, you can stand up proud, chest thrust out, and in a loud, booming voice for all to hear, proclaim "why yes! Yes I do!"

E-rxs, Lost in Transit

I see a lot of complaints about the he said/she said that goes on regarding lost e-scripts. Aside from accidentally deleting one, it's pretty difficult for us to lose an e-script. With patients standing at my counter, huffing and puffing, or on the phone with their doctor, I have a procedure that has yet to fail me. Or prove me wrong.
Huffy Patient: My doctor said he sent it hours ago.
Me: Ok. Where did he send it?
HP: Here, of course. This is where I told him to send it. You people do this to me all the time.
Me: Did you ask him what fax number he used? (This is for missing faxes that usually go elsewhere.)
HP: No. That's your job.
Me: But you just had him on the phone. How can you be certain he sent it to me?
HP: He said he did.
Me: Fine. Allow me to call him.

Office Lady: What now?
Me: HP says you sent his prescription over via fax or e-escript.
OL: We did. At 11:17 this morning. It says so right here.
Me: Where did you send it?
   Option #1
OL: We told him we sent it to ABC Drug.
Me: Awesome. You do know that I am XYZ Pharmacy, right?
   Option #2
OL: We sent it to you. You are XYZ Pharmacy, right?
Me: I am. Now can you verify my information as to where you sent it? Since I obviously do not have it, there must be a problem on my end. I get tons of e-scripts and faxes from other offices all day and would like to figure out if I have to call my people to fix it.
OL: Let me check this next screen. Wait. Oh. It says right here "FAILED". I guess that's why you didn't get it. Let me resend it.
Me: Just give me a verbal. I can't trust you now.

Why are there two screens? Why does the first always say it was sent, but the second screen is the one that tells them "failed"? So far, I am batting 100% when I ask them to check the confirmation screen after they tell patients they sent it. They even give them an exact time it was sent. Great. Your office may have hit "enter", but it does not mean it "sent".

No Means No

How many licks does it take to get to the center of a Tootsie Pop?
How many "NO's" does it take to get someone to understand No Means No?

Impatient Patient: Did my doctor call anything in for me yet?
CP: No.
IP: Nothing?
CP: No.
IP: Not for my blood pressure?
CP: No.
IP: I called him this morning. Nothing, huh?
CP: No.
IP: Yesterday, perhaps?
CP: No.
IP: Not my antibiotic either?
CP: No.
IP: Maybe last week then?
CP: No.
IP: Are you sure?
CP: No. I want to see how long we can keep this going. Ask me if he faxed anything.
IP: Ok. Did he fax anything for me?
CP: No.
IP: But you said...
CP: And you listened. Now try voicemail or e-scripts, or email, or secret courier.
IP: Did he e-scribe it?
CP: No.
IP: Email?
CP: No.
IP: Is it on voicemail?
CP: No.
IP: Did it magically arrive via secret courier?
CP: Um, No. But I like the way you think.
IP: Well what else is there?
CP: Morse Code?
IP: Is it worth it?
CP: Not really. But I'm amused. Of course by this time, I now have to check my fax machine, my e-scripts, my voicemail, my email, my Pony Express satchel, and Top Secret pneumatic tube all over since it's taken me so long to get you to understand no means no.
IP: <optimistically> How about now?
CP: No.
IP: Ok. I'll wait around for it.
CP: Of course you will...

Do You Have any Medication Allergies?

Stupid is as stupid does.
We always ask for any allergies to medications when patients drop off prescriptions. Why? Just to annoy them and take longer to fill their prescriptions? As a sort of pop quiz? Just to watch them squirm and get that far-off, deep-in-thought look in their eyes? Of course!
The responses we get are either "they're on file" or "I can't remember" followed by "why do you always ask me?". Well, last time you were here, you got a new medication. Perhaps you developed an allergy to it. Perhaps you made an ER visit where they administered something to which you were allergic. I don't know. All I know is I need to have the most current information on file to do my job. The only person who can supply that, is you. Therefore...the reason we ask every day.
Does your doctor ask for current insurance information at each visit? And do you whine about it?
Does your doctor ask for your current med list with each visit? And do you bitch about it?
Does your doctor verify your address? Or pharmacy of choice with each visit? (If not, they should.)
Why complain about what people are required to do in order to do their jobs?
The other reason, is to verify what someone else may have mistakenly added to your chart.
An office, that specializes in pain and its management, uses a prescription program that lists the patient's allergies on each prescription. This is distracting, but is also helpful...Unless they don't make sense. The allergies listed, by the doctor's office, for one patient were: ANCETS, ENDOSYN, and PERIDYIM. I know what they should be. Shouldn't someone in that office be responsible for ensuring accuracy? What use is an allergy list if not one of those is spelled correctly? What use is it if it makes no sense? We asked the patient (due diligence) and were given almost the same list, verbatim. We verified the specific medications and reactions and updated our file. Remember, the information is only as good as what is entered. Garbage in equals garbage out, right? This goes along with the office staff that call in nonsensical gibberish as drug names and respond with "well that's what the patient said she was taking or that's how she spelled it to me". How about your own due diligence? Ask a follow up question, check the chart, know what you are calling in, know what you are adding to the chart. It's not as if a severe allergic reaction could kill a patient or anything, right?

Obey the Law

Rules, as they say, is rules.
I believe we have to live by them. All of us, by the same ones. Why do doctors always act as though we are just being a pain in the ass when we call them on something? For years, since I was an intern even, it has been illegal in my state to use a rubber stamp or other mechanical means for a doctor to sign a prescription. Yet somehow, I still see one occasionally. What happens when I call the doctor to alert them to this? (Mind you, all I am seeking to do is inform them it is illegal and to take it down now as a verbal order. Simple, right?)
Me: Is your office using a stamp for the doctor's signature?
Phone Lady: Yes.
Me: Did you know it is not a legal signature?
The responses generally come out as one of these:
PL: Why not? It's just...Amoxicillin, or It's just a Z-Pak, or It's just a Bowel Prep, or The doctor is out of the office today.
Me: I don't care what "it's just". The law states that a doctor must manually sign a prescription in the manner in which he would sign a check or legal document. That means with a pen. There are no exceptions for cases where "it's just amoxicillin" is acceptable.
This is usually followed by PL telling me I am the only pharmacy or pharmacist that calls them on this, that they have been doing this for years. Right. I am the only pharmacist who cares about my license. Apparently, all the other times I called, you ignored me. I even had people tell me their doctor told them not to come to my pharmacy because I don't accept their prescriptions. Wrong. I don't accept invalid prescriptions from offices that are too stubborn to obey the laws. Seriously, is it really that difficult for a doctor to scrawl a line on the bottom of every prescription that he writes? Usually, the offenders are writing for medications for procedures and the prescriptions are often preprinted for him. It's not as if they are prolific scribes penning the next War and Peace and they risk their hands getting fatigued.

Did you ever Wonder?

I am pretty good at math. Always have been. I can do most pharmacy calculations in my head rather quickly. If you need a calculator to double-check, please grab one. I mention this because I always wondered why people would prefer to argue with me, when I am obviously right, rather than acquiesce. I present two cases today:
1. Birth Control: There are 365 days in a year. In order to give someone a year's supply, most doctor's offices will give patients 12 packs (usually 1 pack with 11 refills). This is not enough. How many months have 28 days in them? (All of them actually, but most have 30 or 31...) This is where the problem lies. If they are scheduling patients to return in 1 year, 12 packs will last 336 days, 13 packs will last 364 days. She will still need a 14th pack. I called a nurse out on this when she called in 1 pack with 11 refills.
Combative Nurse: That's 1 pack with 11 refills. Her appointment is next year.
Me: Ok. But she'll need 14 packs to get her through until then.
CN: No. There are only 12 months in a year. She will be back in 12 months. Therefore she needs 12 packs.
Me: But there are only 28 tablets in each pack. You are only giving her enough for 336 days. There are 365 days in a year.
CN: That's how we always do it.
Me: Ok. Then you always do it wrong. Grab a doctor and a calculator and call me back.
(Yes, most gynecology offices know better. Yes, they sometimes give patients free starter packs. The point is, outside of that being true, this conversation happens. It is not legal, here, to put "refill x1yr" so that is not an option.)

2. Pain Meds (and others as well): Everyone has a rule about how early we fill controlled substances. Usually it is 1 or 2 days early. Ever wonder what happens to those cumulative refill quantities? If someone fills his prescription 2 days early every single month, assuming a 30-day supply, at the end of the year, he will have an extra 29 days of medication somewhere! Where do they go? If we are so concerned about early refills and abuse potential (obviously legitimate patients are not being discussed here), then how do we deal with this issue? Some insurance companies will stop refills on heart or cholesterol medication if the cumulative refills amount to too much over a certain period of time. Has anyone ever really looked at these "repetitive creep" amounts? I know we can research these fills through some states' Prescription Monitoring Programs and alert doctors but what else can we do? I've had the "cumulative refills are too soon" conversation with a number of patients and doctors. Most of them have been quite receptive but some are argumentative. I am not talking about shirking our duties of having the conversation with the patient and doctor about how much they are actually taking, dosing increases, strength changes, status changes (pre-op vs. post-op vs. accident, etc). This is simply about the woman who presents a prescription early for Vicodin 5/500 written for 4 times a day for 120 tablets and always shows up saying she is out or needs them right now, every single month.
Where did they go?

Staff Auto-Correct

In a fast-paced, noisy environment, it is our duty to ensure accuracy. This means even when others will not cooperate with us.
How do we ensure accuracy when taking verbal orders from a practitioner's staff over the phone? The easy answer is to repeat back to the nice caller, all of the prescription information they gave us. I like to take it a bit further and clarify what I heard since enunciation is often overlooked for the sake of speed when phoning prescriptions into a pharmacy.
Office Person: Calling in a prescription.
Me: Go for it.
OP: Tramadol 50mg BID for a month.
Me: Okay. So that's take one tablet two times a day?
OP: No. He wrote BID.
Me: So twice a day?
OP: No. It just says BID.
Me: Yes. BID is archaic Latin for Twice a Day. I'd like to clarify this since you mumbled and I couldn't tell if you said BID or TID. Besides, if you're in charge of phoning in prescriptions, you should have some idea as to what the secret codes are.

I also have the issue where I repeat something and then get corrected for pronouncing it correctly. If I'm trying to clarify what I heard, don't just mumble over me again. This is especially true of medications that sound alike.
OP: **sinopril 20mg.
Me: So that's LI-sinopril 20mg?
OP: No. It's ***inopril 20mg.
Me: So, FO-sinopril 20mg?

OP: That's Omeprazole 20mg.
Me: Ok. Generic for Prilosec 20mg?
OP: No. He wrote Omeprazole.
Me: Omeprazole is the generic for Prilosec. I'd like to verify this too since some prescribers like to use the generic names exclusively, regardless of if they are available in the marketplace because that's how they were taught in school and it can be confused with Esomeprazole, generic name for Nexium.

I'm not trying to correct you. I am trying to get the correct information for the patient. If you don't know the answer, please turn around and ask the doctor or another staff member for it. Then learn from it so every other pharmacist in town can benefit from our little chat today. If it is your job to call pharmacies, take the time to learn a little about what you are doing. It is a big responsibility and many of the staff with whom we interact on a daily basis are fantastic. However, there are the people outlined above I still talk to years after I became a pharmacist that have not learned anything...