Guest Post from Mr. Dispenser: The Back of It

Thank you, Mr. Dispenser for this great guest post! It’s about how prescriptions are paid for in England, geared towards the US audience. It’s quite enlightening and very interesting. I hope you guys enjoy it. If you get a minute, you should check out his blog. He’s a great writer that I always enjoy reading. My US counterpart can be found on his page.

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The Back of It

In England, the majority of people get free prescriptions if they qualify through 13 categories. Although, I really wish patients would stop asking me what they should tick on the back of their prescription!

 

 

The categories are:

A] Under 16 years of age

It makes me chuckle when people tick income support on their babies’ prescription. The parents fill in the prescription but writes down her exemption instead of the child’s.

B] 16, 17, 18 AND in full time education

If you leave school at 16 and get a job, then you pay. Students start university at 18 years of age and get quite upset when they hit 19 and realise that they have to pay. I have seen students blatantly lie about their age even though it is printed on the prescription.

C] Over 60

The people who use the most medicines get free drugs too. The pharmacy staff sometimes fill out the back of the prescription for people who are exempt by age, when we receive the prescription from the doctors. Sometimes, they tick over 60 when they patient is not. One day, I will get a slap when handing out a prescription for an insecure 55 year old lady

There is no requirement for someone over 60 to sign the back of their prescription if it is a printed prescription as it’s obvious from the date of birth that they will be exempt. Depending on how grumpy the person is, I do or do not make them sign.

Sometimes you may ask someone to pay and they say that they are over 60 and it’s confirmed by looking at the prescription properly. If you apologise and say that they look good for their age, then you will get brownie points.

D Maternity exemption

Once you get pregnant and up to the child’s first birthday, your prescriptions are free. Sometimes, ladies will ask me if I want to see their exemption card but I say that I can see their evidence. This is either a big bump or a baby.

Sometimes, this is ticked by a man with medical exemption by accident which causes much hilarity and embarrassment for the man.

 

E] Medical Exemption

People with certain conditions get free prescriptions. These include epilepsy, diabetes and under active thyroid. Recently cancer was added to the list which is excellent. However, my Auntie was over the moon when she got diabetes as she now has free prescriptions for life.

F] Pre-payment certificate

If you do pay for your prescription, then it can get costly. Each item costs £7.65. If you need more than 4 items in 3 months or 14 items in 12 months, then a three or twelve month pre-payment is a good option. They cost £29.10 and £104 respectively. Then you can get as many prescriptions as you want.

Unfortunately, some people don’t believe that it is a good offer. I once wasted 5mins of my life explaining the benefits of a pre-payment complete with calculations and my working out and they couldn’t be bothered. I’m more upset about having to do some calculations.

G] War pension

Former soldiers are also entitled to free prescriptions.

L] HC2

People on low incomes can apply for a HC2 certificate. This is normally but not exclusively used by students once they turn 19. It normally depends on how much savings they have, whether they work and how much their parents earn.

X] Free of charge contraceptives  

All women get free contraceptives on prescription. Some women who have another non-contraceptive item on the prescription, sometimes conveniently forget to pay for that item and just tick X. These women get chased after by overweight pharmacists.

H] Income support

This is the most common benefit that is ticked on the back of the prescription. This is also the default option when people don’t know what to tick. Some people who can’t speak English just say ‘H’ when asked what they tick. It is also normally ticked by people in expensive cars who have just come back from holidaying abroad

K] Jobseekers allowance

This is another benefit that is given to some people. It is normally ticked by people in McDonalds uniform and taxi drivers

 

M] Tax credits

Another benefit that is generally claimed by people who work part-time or have a partner that does. Some pharmacy staff claim this. There is sometimes the awkward situation when they don’t want to accept any more hours at work as it will affect their tax credits.

S] pension credit guarantee credit

I have never seen anybody tick this option

Prescription Charge

The prescription charge is a contribution to the NHS. It is not a payment to the pharmacist. It bears no relationship to the cost of the medication. It is currently £7.65.The quantity of each item is irrelevant.

There are some anomalies. A pair of hosiery stockings carry two prescription charges. If you are prescribed the same drugs in different strengths is only one charge. A drug prescribed in two different formulations is two charges.

False exemptions

There is a great opportunity for patients to tick anything on the prescription. At the end of the month, all the prescriptions get sent off to The National Health Service Business Services Authority for payment. Less than 1% of the exemptions are checked by them. So it is highly likely that you will not get caught unfortunately.

There is an ‘evidence not ticked box’ on the back of the prescription for the pharmacy to tick if the patient has not provided any evidence. Pharmacy contractors are in no way responsible for the accuracy of a patient’s declaration; this remains the responsibility of the patient. Patients found to have wrongly claimed help from the NHS with the cost of their NHS prescriptions will face a penalty charge and in some cases prosecution.

If the patient does not tick anything on the back of their prescription and it gets sent off, then £7.65 is taken off the pharmacy. It is in the pharmacies best interest to ensure that the back of the prescription gets filled in.

 

Mr Dispenser

My blog can be found here

Health Insurance…My Other Specialty?

 

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I am apologizing ahead of time to my non-US readers for the confusion you will probably feel after reading this entry. Our health insurance situation in the States is screwy a lot of the time.

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Working in a community pharmacy in the US means having to deal with insurance companies about 1/3 of the day. This is true of both techs and pharmacists. We both need to know how to handle phone calls about rejected claims. My story for today is about how tiresome it can be.

I received a call from a woman in the early afternoon asking me if I remembered her situation. After talking to her, I realized I did, in fact, recall dealing with her last month. Her story was complicated, so I was glad I was able to recall the details. This woman’s insurance provider changed their plan details at the beginning of June. Same company, same representatives, but a different plan. This isn’t exactly unusual here in the States. Patients will have everything on their ends stay the same, but things on the insurance carriers’ ends change dramatically. For this woman, this not only meant that she was forced to only come to our pharmacy for prescriptions, but that the amount of pills she could get when first transferring would be different as well. She had always been allowed to get a 90 day supply of her maintenance medications before June. Now, the regulations state any time she gets a new medication that she’s never had before, she must pay her full copay for a 30 day supply first and then in subsequent refills, she can get 90 days’ worth. This wouldn’t be that bad, except that every time she goes to get her pre-existing prescriptions filled for the first time since June, they view it as the first time she’s ever had it ever filled and denies a 90 day supply. It always leads to both the pharmacy and the patient having to call and argue with the insurance provider.

Well, she called and told me she had two other prescriptions that were due to be filled. I told her I would handle the situation like last time, and she thanked me. The prescriptions were put through and (no surprise) they rejected a 90 day supply. I called and got a hold of a representative with a god complex, who told me that this override didn’t exist and that it had never been done in the past. I argued with her, trying to get her to see that it had been done last month with other medications. She basically told me it was a fluke and refused to provide any assistance. I had to call the patient, who then called the insurance provider herself. She returned my phone call a bit later and gave me a specific number to call. I called this number and was transferred to three different departments before someone was finally able to help with the situation. The actual override took about 30 seconds and consisted of a couple keystrokes and computer mouse clicks. The total time I spent dealing with this problem (which really shouldn’t be a problem) was about 45-50 minutes. I was so backed up afterwards that I had to stay an extra half hour after closing to finish checking the rest of the filled prescriptions for the day.

These kind of things are so beyond confusing and take up so much time that should be spent doing ACTUAL pharmacist duties. Because of some error in that insurance provider’s system, not only was time taken away from me, but it caused so much unnecessary stress on the patient. She shouldn’t have to call them in order to get them to listen. That middle man step should not be necessary. But, this is always the case with her medications. I’ll be happy when everything is finally all transferred over from her old pharmacy once and for all. The worst part is that her situation isn’t the most unusual thing I see. There’s a set of quadruplets that when they need medications always require a phone call to the insurance company because they are unable to provide them with their own identification numbers, so any activity appears fraudulent to the provider at first glance. Why they can’t have their own ID numbers is beyond me, but all I know is it causes four children to wait an hour and a half or longer for antibiotics when they all get sick when it should take no more than fifteen minutes.

All I can say to really sum everything up is this:  I wish my pharmacy would institute a call center like they’ve been talking about for years now. It would cut down on a lot of this unnecessary stuff and allow more time for patient contact. It would allow more time for me and every other US community pharmacy to actually practice pharmacy.

 

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Mixing Flavors

 

We all remember how some of the liquid medications that we had to take as children tasted. There was yummy, bubble gum amoxicillin. There was disgusting, bitter Augmentin that we could barely tolerate enough to swallow. There was sweet, grape Dimetapp that soothed a sore throat and quieted a cough. Those are just a few I personally remember be given as a small child when head colds, strep throat, and walking pneumonia came my way. Unfortunately for me, the flavor of the medication was what it was. I just had to deal with it if it was nasty. Today, there is the option to flavor liquid medications if the original flavor is yucky. The brand of flavoring drops we use at my pharmacy is FLAVORx. I feel it works pretty well, and it’s a reasonable price ($2.99 USD per prescription). Having personally taste tested many of my “creations”, I feel comfortable telling my patients which flavor is their best bet to cover up the “yuckiness”.

There are some people, though, that cannot afford the service very easily. We have a high welfare population in my area, so I try to tell these people other ways to diminish the bad flavors. I also offer to flavor it at any time if they find it just too difficult to swallow it as is. The one thing I always tell people is to have a “chaser” ready for the really bad tasting things (Augmentin, Cleocin, etc). I also tell them to try sucking on an ice cube or ice pop for a few minutes prior to administration to help dull the taste buds. I always recommend keeping things in the fridge for the medications that don’t have specific storage requirements (azithromycin, prednisolone, etc). Most people find a combination of factors that works, and if they don’t, they come back in a day or two to ask for the flavoring service.

My story today is about a mother who was picking up some liquid allergy medication for her daughter. She asked me if it was okay to put it in the fridge. I told her that was fine and would help improve taste. She commented that taste isn’t a problem since they always mix the medication with whatever beverage she is having at the time of administration. She began listing off every drink you could think of–soda, milk, juice, tea…you get the picture. I asked her if someone had told her it was okay to do this with the medication. She said she came up with the idea by herself. Instead of going through each drink to see if it was okay to mix the medication in them, I asked her to refrain from doing this because I was unaware if it had any negative implications. She seemed confused, so I explained there are some medications that if mixed with or taken at the same time as some beverages could essentially be made inactive in the body. She nodded, and asked for tips on how to make the taste less bitter. I gave her my normal spiel, and she thanked me. She ended up coming back later to ask for the flavoring service just to make sure it was palatable enough.

My advice here for my readers is to never mix liquid medications with other beverages without contacting a healthcare professional (preferably a pharmacist) first. You want to make sure the drug is as effective as possible when taking it. Whether it be by finding something that is acceptable to mix it with or by flavoring the medication itself, we can help you figure out a way to make it less yucky.

 

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Sticks and Stones May Break Your Bones…

 

Today, I got to see one of my favorite patients. It helped make the otherwise hectic day a bit easier. There’s a funny story about how I connected with this person that I must explain first.

Not long after I started working at my pharmacy, this woman came in to get her husband’s medication. She was very rude to all of our staff, so I took note to remember her name, so I knew when I needed to be extra nice and calm. Then one night, she came in to get some inhalers filled and had no idea how to use them. I took the time to explain the technique, and, ever since, we’ve been on great terms. She looks for me and trusts me.

Back to the present… She came in to get her husband’s meds filled and shared a shocking story with me. Almost two years ago, he had extensive surgery in multiple areas of his body. Ever since, he has been nearly bed bound due to the pain resulting from the surgery. They told him he just handled the procedure poorly, and that his only option was pain management. So, for the past 18 months, the poor man has been on and off all different pain regimens.

Desperate for any answers, the couple decided to get a second opinion because he did not like being on all the pain meds. His wife told me today that the other facility he went to informed him some of the rods, pins, and screws were placed incorrectly during his original surgery. She told me the original surgeons refused to go back and fix it. She stated they were going to go out of the area to try to get it fixed.

I was appalled by her story! This man has such a poor quality of life right now, and the surgeons won’t attempt to fix the mistakes they made? That screams unethical to me. It also has “potential lawsuit” written all over it. Even if they don’t feel comfortable opening him up again, they should have at least told the man the truth about the surgery outcome instead of covering it up. According to his wife, the second facility needed only to look at basic imaging studies to know that the hardware was placed incorrectly, so the original surgeons should have been able to tell a mistake had been made.

Lying to a patient is bad and unethical, yet healthcare professionals do it. It usually comes back to bite you in the end. My only hope is that this man can get the mistakes fixed to a point where he can have a decent quality of life again. =/

 

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Facepalm

 

Today I came across a huge “no-no” at the pharmacy. The worst part about the whole situation was the fact that I couldn’t get the patient to understand why it was so bad.

A woman came in to fill some lancets, insulin, and syringes. Noticing we had no diabetes medications or supplies in her profile at all, I asked her if she need a script for test strips as well, offering to call the doctor if she did. She said she didn’t because she wasn’t out of them yet. I started inputting the scripts to give her a price on them after her insurance was billed.

It was relatively inexpensive (less than $10 each), considering the price of the insulin without insurance. When I gave her the total, she groaned, telling me money was so tight that even that was a lot. I felt bad. I hate that the economy makes people choose between prescriptions and other necessities. She decided to only get the insulin and syringes. I apologized for the price. Up to this point, this was a normal interaction tinged with sadness. That’s when these words were spoken:

“It’s ok. I’ll just keep using the lancet that’s in the poker right now.”

I warned her this wasn’t a smart idea because she could cause herself an unwanted infection. She shrugged her shoulders and told me she’s been doing it for years. She also told me she reuses her syringes multiple times until the needle tip gets bent. In my head, all I could think was, “ARGH!!” Again, I told her this was bad news bears, emphasizing how important using a clean needle every time was. She laughed, saying, “Honey, it hasn’t killed me yet, and it’s not going to any time soon.” I wanted to bang my head on the wall.

So after that, I filled her prescriptions. When I started ringing her out, I reminded her that she should discard her insulin vial once it’s been opened for 28 days. She laughed again and told me she liked to try to stretch it as far as it can go. I told her that it wouldn’t be as effective, and her blood sugar readings may be more uncontrollable after that point. She smiled, winked, and replied, “I’ll think about.” That’s when she left.

Reflecting on this, I’m still shaking my head. Reusing things that pierce your skin is a HUGE “no-no”. You put yourself at risk for infections. I have heard of many people using lancets over and over, including a family member of mine. This is not unusual, even though it’s bad. But reusing syringes?? That’s just awful and, in my opinion, gross. I shudder thinking about it. It’s a step below sharing needles.

Readers, I know times are tough and money is tight, but please don’t reuse anything that pierces your skin. It’s not worth the potential complications it can cause. Syringes aren’t too expensive out of pocket, and every insurance I’ve ever billed covers them for diabetics. Don’t risk a massive skin infection or worse in the name of penny pinching. It may cost you much, much more.

 

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Expiration Dates

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Today’s theme was drugs past their beyond use dates and what that actually means. There were several people who called or stopped by to ask about it. People tend to call it the expiration date, but that’s not the best choice of words, since most drugs do not actually go bad at that date.

One person that stuck out in my mind was an elderly lady who called to ask if her husband could use the Nasonex they had in their house. I asked when it was dated for and she told me February of 2010. I told her it was best to get a new one if possible. She told me money was tight, so I told her to ask her physician for samples or to see if they had any copay coupons available for their patients. I also told her to ask about generic alternatives, since he had never been on anything but Nasonex. She thanked me and hung up.

So, what is a beyond use date? It’s the date that’s stamped on drugs (prescription and OTC alike) that you should use it by. So what happens on this magical date? Does the medication suddenly turn into a pumpkin, like the carriage in Cinderella? No. Most of the time, all that date represents is the date at which the medication is no longer guaranteed to be more than 90% effective. There are only very few drugs that actually go bad or become toxic after their beyond use dates. So, what does this mean for you? Well, if you have something in your cupboard that is dated for a few months ago, taking it is probably not going to cause any harm. You’re just not going to get the effect from it that you would if it were new.

There are a few exceptions to this. The following should not be taken past their beyond use dates. The list is not all inclusive, so always ask a healthcare professional before using a medication beyond its date on the container.

1.) Tetracycline and all other drugs related to it. These drugs actually become toxic once the date passes, so for them, it truly is an expiration date. Do not take it, even if the date has very recently passed.
2.) Birth control pills and other female hormonal supplements. Typically, women using these are trying to either prevent pregnancy or prevent other reproductive medical problems. Taking these when the date has passed can result in an unwanted pregnancy or the return of gynecological symptoms.
3.) Antibiotics besides tetracyclines. You want your antibiotics to be as effective as possible, so it gives your body that best chance it can to fight off that infection.
4.) Nitroglycerin tablets. These are meant to stop a heart attack in its tracks until you can call an ambulance. Once their brown glass container is opened, they are only effective for 6 months afterwards. Keep these up to date in case you ever need to use them. You want them to work as well as possible, since they can save your life.
5.) Blood thinners, such as Coumadin (warfarin), Pradaxa, aspirin, etc. Some blood thinners have a very narrow window of opportunity to do their jobs correctly. By using these after the date has passed, you’re at a risk for blood clot development and all the things that come with it.
6.) Digoxin and its family members. These control the heart rhythms of people with heart arrhythmias. It seems like it would be common sense for these to be as effective as possible, since your heart is (in many ways) in charge of your life.
7.) Insulin. Once the vial or pen is opened, it only stays effective for 28 days. Using it after that point will not keep blood sugar levels controlled as well.
8.) Test strips and control solution for blood glucose meters. They will not give you accurate readings if they are past their dates.
9.) Anything in a pharmacy provided amber vial. This vial can only guarantee a year of efficacy, which is why they all say to dispose of any unused medication after a year from the date it was filled.

Like I said, this list is not all-inclusive, so always double check with a healthcare professional first. These were just the most important ones that popped into my mind.

I hope your days are all going well!

 

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Refusing

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So, today was a relatively busy day in the pharmacy. It was pretty much non-stop action all day. It wasn’t a bad busy, just busy. The day flew by pretty quickly, and most people were in good moods. I’m sure the sunny weather helped with that. =)

There was one man who came in today who had both a Medicare part B and Medicare part D plan. Both will cover diabetes equipment and drugs, but with varying copays. We had originally billed his prescriptions through Medicare part B just over a month ago. He received a letter in the mail the other day telling him that he has had Part D coverage for those prescriptions for a few years without realizing it. He asked me to rebill it through the Part D plan. I willingly obliged.

Well, it turns out one of the prescriptions was the same price either way, but the other was cheaper through Part B. I tell him this, and he asks me to undo the second one. Unfortunately, once it’s been over 30 days, you can’t undo things like that in our store. You can only bill under new plans. You cannot rebill and then undo it because it was cheaper the other way. That is technically fraudulent behavior. You, as the patient, are responsible for knowing which billing option you want to use beforehand. The pharmacy can only rebill and refund under very certain conditions, especially with government funded insurance (Medicare, Medicaid, Tricare, etc.).

So, because the price difference wasn’t that much, I was just going to absorb the cost, since he wasn’t previously aware of the price difference, but he wanted to hear nothing about it. Before I could tell him that I wouldn’t be charging him extra for it, he walked away and out of the store. That left me with an interesting story for my store manager tomorrow morning when the register is all totaled.

Listen, if you are ever in a situation where rebilling something makes it more expensive for you, most retail pharmacies will absorb the difference and not charge you. But never EVER just leave without completing the refund transaction. We need you to sign receipts verifying you were present for the transaction. Otherwise, the store can get in trouble. This is mostly for chain store pharmacies, but even for independents…it’s just plain courtesy to stay until any transaction is finished.

 

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