Calling an Insurance Company

For anyone who has ever worked in a pharmacy and had to deal with insurance claims and issues they know how frustrating it can be. Many times insurance doesn't do what you want it to do, and you end up not only frustrating the customer, but being angry with the fact that something has gone wrong along the line of processing.
Some of the general insurance issues that I run into on a regular basis include the following:

• Missing or Invalid Patient ID/Processor Control Number/Group ID
• Missing or Invalid Patient Age or Gender
• this is usually a flub by the insurance company because most times the patient is there letting you know their birthday and the gender of their children
• Missing or Invalid Patient Person Code 
• 01-Cardholder 02-Spouse 03-Child 
• Prior Authorization required
• Doctor and Insurance company must come to an agreement 
• Missing or Invalid Day Supply 
• this is often an easy fix, if the prescription was written for a 90 day supply and the patients insurance company-usually Medco, only lets the patient receive a 30 day supply at a time, you simply change the dispensed quantity to that within a 30 day range of time
• Sometimes if a patient has switched or increased their dosage and we have not yet received the prescription from the doctors office-we will need to call and let the insurance company know that there has been a change in dosage 
• If the patient does mail order and they haven't received their mail order drugs yet and need some to get by 
• Override Codes Needed
• Diagnosis Code
• this may be a company code or a specific insurance code
• generally when a code has been used the pharmacy intern, tech, or pharmacist will put a note in the patient profile so that the next person who tries to submit a claim for them doesn't have to go through the hassle of calling the insurance company 
• Vacation Override Code
• when people are going on vaccation and need an advance on their medications ahead of time
• Transplantation Codes
• liver, kidney, etc transplants need a certain code for insurance companies to pay for their medications which are often extremely pricey 
• Company Codes
• For Hy-Vee by putting a 999999 you can often override rejections that the system sees as inappropriate 
• these could include DT: duplicate therapy DD: drug dose or others as well 
• Vaccination Codes

There are many other codes that could qualify for these as well.

When one gets a rejection, they generally try to do all the different "Tricks" that they can think of to try and fix the problem without calling the insurance company, but this doesn't always hold true. Many times the insurance company needs to be called which can be a heinous task.

Here is how many phone calls to the insurance companies go:
"Hello and thank you for calling Express Scripts (or other insurance company)"
If you're calling in regards to a refill request press 1, if you're calling for a rejected claims press 2 etc etc  and many times instead of having you press a number they will have you say "refill" or "claims" this is often erroneous in itself because many times the robot on the other end can't decide what you're saying.

It will then ask you the RX or prescription number that you're requesting to receive information about, and thereafter it will ask you other information such as your NPI number, phone number, and name. Then hopefully after this you will be able to speak to an actual person about your claim that you have questions on.

When you get to talk to a person you then will be asked the questions over again and then asked what your problem is. Many times the person on the other end will either have you go about adding codes or changing things until you get a paid claim, or they'll change the information from the main server and then have you try to re-process the claim yourself. Other times this is not so easy and they will have you require a Prior Authorization from the doctor for the doctor to contact the insurance company.

Many times the insurance companies want the patient to call them with questions about their medications, but if I was a patient who had never dealt with any issues in the pharmacy before I would be dumbfounded as to how to answer the questions that the insurance company asks. For this reason the pharmacy staff needs to be well educated on issues and insurance information.

DEA forms 222

Many pharmacy technicians when they first start to work in a pharmacy, along with pharmacy workers or anyone who hasn't been around a pharmacy setting in their life before are new to the idea of what CII is and that there are many different restrictions to what you can and cannot do with these drugs. Besides the fact that these prescriptions cannot contain refills, must have the name, birthday, and address of the patient listed on them along with other information, they also have very strict ordering and receiving policies. When I first started at the pharmacy we had a certain person who was able to the CII orders, but one of the times that it got messed up, they restricted the ordering to the pharmacists at our pharmacy. At the new pharmacy I work at the pharmacist is the only one who orders CII's.

To do so requires what is referred to as a DEA 222 form, and it looks somewhat like the above posted. The DEA 222 form has three different parts, the top part which you can see here, and two carbon copies for filing and keeping for a certain amount of years.

Here is some of the pertinent information that one should know regarding a DEA 222 form:
1) first and probably one of the most important, is that you can't "erase" or "cross out" mistakes, if you make a mistake you must cross through the document and keep it on file as a mistake record. Because if there is a problem on the order the manufactures then regard this is worthless.
2) These voided or unused forms must all be documented and tracked, along with the used and filled out forms as well
3) If one should lose a DEA 222 form or multiple DEA 222 forms, they have to report this to the DEA office as soon as they realize it.
4) Copy 1 and 2 are sent off to the manufacturer in a certain envelope that is provided and the last one is kept for the pharmacy's personal records.


When a CII order is received the following needs to be done as soon as the order is received if possible:

Required Information for Purchasing Records (DEA website)

The following must be recorded or appear on the invoice when acquiring controlled substances:

• Name, address, and DEA registration number of supplier or manufacturer from where this is from
• Name, concentration, dosage form, and quantity of controlled substance
• Signature or initials of authorized user receiving the shipment or pickup
• Date received

At our pharmacy this is all done by the pharmacist and kept in a certain CII booklet that is always checked before the end of the night. 

This is only a small insight into what it is like to deal with DEA 222 forms but even by this we can tell that it is something that you have to take seriously and know what you're doing before you proceed to do so. Many pharmacies have different methods of how they do this and their check methods, but either way this is something that needs to be done by a trained professional who knows what they're doing and how to do it. 

Pulling Outdates

Medications are given an expiration date and lot number by the manufacturer. The expiration dates are determined by the pharmacokinetic properties given to the drugs and are extremely important. Many people are under the impression that even though their medication is past the expiration date, especially with OTC products, that they can still use these medications. With some medications this is true, the only problem is that the potency of the drug will be lessened, however with some other drugs they may lose almost all of their effect after they've become expired. Because of this fact it is very important that pharmacy technicians and pharmacists make sure to pull out dated drugs regularly. There are many different ways to go about doing this in a community pharmacy.

One of the main ways to make sure that the expired or outdated drugs have been pulled from the shelves and not been dispensed is to first have a clear and organized system, and way of doing things. The way that we do it where I work, is when we do inventory, or count all of our drugs we make sure to check the expiration dates on the products. We then sticker the ones that are going to become out-dated in the next several months. This then will be put on a sheet and they will be pulled on the first of every month. Once pulled they're set aside to then later either be shipped back to the company and hopefully there can be money reimbursement for the product, either that or the store will just take a loss.

To make sure that drugs that are going to become expired within the next several months don't go to waste, there are different ways that pharmacists can try to get rid of the medication before it expires. Between the different pharmacies there is a vast network of communication  and many pharmacists send out email requests and ask questions about different medications, for example one such email could look like the following:

"Looking for Clonidine 0.1mg #60 if anyone is looking to sell"

Hy-Vee #28942

Once this message is sent out many other pharmacies can check their inventory and see if they have any they need to get rid of, and often times this is how many people can get rid of their soon to expire drugs as well, by asking others if they need any of the medication. It's a great system and can help save resources and money, so it is very important to always know the expiration dates on your inventory.

Pharmacy School Curriculum: Pharmacokinetics and Biopharmaceutics

As a second year pharmacy student going through the regular classes that all students need to obtain their pharm D degree, I find it extremely hard to gain any benefit from the following classes:

• Pharmaceutics: Solids and Semi-Solids
• Pharmcokinetics and Biopharmaceutic

I have completed the first class, and am almost finished with the second class, and unfortunately will have another pharmacokinetics class next semester as well. What I can honestly say that I have learned from these classes-and not for a matter of not trying-is that I understand "like dissolves like" and that there is such a thing as First Pass Metabolism. Other than these two fundamental concepts, there is not much more I understand or have learned from this class. The way this class is taught at the University of Iowa at least, is not benefiting me as a future pharmacist, or helping me do well in other classes. The main classes that matter I'm doing fine in, but this class which many pharmacists now will tell you is completely pointless, I struggle. It's not a matter of me not studying, or the professors being completely terrible, but the subject matter is something that I believe one should not have to be tested over. 

One of the first things that they tell you in these classes is "there is no black and white" everything is very variable and dependent on individual patients. So how are we supposed to be tested on something when we have to take into consideration the certain circumstances of our clients? The way that my first exam for this class was structured was I was handed a 50 page handout of package inserts and drug product information along with the actual 18 page exam itself. I was then asked questions such as "What are the purpose of the following excipients in this product?" It angered me because the questions on the exam were questions that when pharmacist get ask-which I doubt is frequent-they learned the drug information resources their P1 year and can confidently search for this information in a quick and easy manner. I can't justify learning and memorizing different types of excipients when they're doing something different in every product. Nor do I believe that it is important to know the exact size of alveolar sacs and how fast a nasal spray is going to travel into the back of the throat. Along with this the fact that we received 50 pages to read for 5 point quizzes over anatomy questions to better our learning didn't do anything but hurt my grade, regardless of how well I studied. 

My main frustration comes with the fact that I go to class, I take good notes, and I try to learn the concepts but they're so old age and not taught in a way that we as students can understand that it makes studying a complete misplay. I have been taught what hepatic clearance, volume of distribution, and area under the curve are time upon time, and yet if you asked me to tell you a definition of them, I couldn't. It's information that is being taught to us in a way that doesn't seem at all important, the teachers themselves even act like they don't want to be there, so how can they expect their students to enjoy what they're learning? It's bad enough hearing other professors at the college say that they as well don't think that they class has any purpose and what they're asking us is ridiculous. I feel that had I gained a better understanding of the basic concepts of what this class is trying to teach us I would be doing a better job in the class, but I even went into office hours last year to try and gain the basic concepts and came out with nothing. So in my opinion as far as testing for this class, I think it is a complete waste of time and that the students are gaining nothing from it. 

How to build and maintain trusted relationships between pharmacist and patient

Building a relationship based on trust is one of the most important aspects of the pharmacists job description, because if it wasn't for the patients, pharmacists would be out of a job in the first place. From working in a pharmacy the last five years I have been exposed to working with six different pharmacist, each one very unique and different from the others, and yet they all have one thing in common: genuine interest in the care of the patient. Working with people’s medications is a very serious job and it is one that requires the pharmacists full attention and effort, and to do so the pharmacist has to be sincerely passionate about what it is they are doing for the patient. By caring about their patients health the pharmacist should be expected to take their time and make sure that they get to know every patient and try to remember something about them so that the patient knows they were listening. Letting the patient know that you are listening to what they have to say—whether it is right or wrong—is a key point to building their trust because it shows them that you do care what they have to say, and it lets them know that you are there for them. When a patient comes in with a question the pharmacist should take time out of what they are doing, no matter how busy they are, to attend to every patient. By doing so they show the patient that they are their number one priority and that they will make time to help them the best way that they can.

            Making the patient feel comfortable is another way that the pharmacist can build the trust of the patient. Many people come in with different questions, some that are often rather difficult to answer, or out of the ordinary, so the pharmacist must be outgoing and not afraid to answer the patients question. Pharmacists must be very open to sharing their feelings with the patients and showing their concerns for the patients as well. The patients that I have worked with over the years always enjoy their trips to the pharmacy because it takes the edge off of things when the pharmacists that you work with are not only viewed as your health care providers but as your friends. After working on a team of 6 pharmacists you stop feeling like employers who are helping patients and start feeling like a family who is helping to aid their friends. The atmosphere in the pharmacy setting can be one full of trust if the pharmacist and the patients are willing to work together.

            To be able to work together and have constant flow between the pharmacist and the patient the patient has to allow the pharmacist to get personal with them all the while maintaining the practice of professionalism. By getting to know these people and letting them know you remember them, taking care of each and every one of their individual needs shows them that you put their care above all else, and that is what is going to create the bond between the pharmacist and the patient. Even in high velocity pharmacies that fill over 900 prescriptions a day it is still very important that you get to know all of your patients, by taking an extra minute to see how they’re doing and taking the burden of the day off their shoulders, because usually the people that are coming into the pharmacy aren’t there for a good reason so being able to make their days even a little bit better should be one of the pharmacists key ways of building a relationship with them.

• Listening to what the patient has to say no matter the situation
• Giving the patient the benefit of the doubt and trusting what they have to say
• Never making the patient feel inferior
• Explaining things to different types of patients at their level
• Being not only pharmacist friendly but genuinely friendly, creating a bond between pharmacist and patient that is not only work and health related but socially related.

o             Working at the pharmacy the pharmacists that I work with are some of the most well respected people in our community and they are always having people stop into the pharmacy even if they don’t need medications but just to visit with our pharmacists

• Getting to know the patients by name and face, not just by what medications they’re taking
• Remember key details about their lives that are important to them and that you can talk about with them the next time they come into the pharmacy
• Always treating them with the utmost respect because you don’t know what they may be going through at the time and so even if they are treating you in a rude manner just always being the nicest that you can be

·                                 Helping them to understand everything about their medications and making sure that they trust your decision making skills by showing them that you know what you’re talking about and that you are keeping them in your best interest

·                                 Making them smile and laugh, keeping the relationship light hearted and not only about them getting their prescriptions

·                                 Making sure that if they wish you talk in confidence that you let them, showing them that you do care about their trust and keeping their information private because many people have different issues that they are in there for that they do not want shared with others

·                                 Overall, building a friendship yet still working still reinforcing the professionalism of the client pharmacist relationship 

Pharmacy Delivery Systems

One of the major complications for the elderly in being compliant with their medications is the fact that many of them cannot drive to the pharmacy to actually receive their medications in the first place. Especially during the winter months when they're concerned with driving in general, they sometimes will just decide that they would rather not take their medications because they don't want to drive. Many elderly patients have family members who can stop by the pharmacy for them and deliver their medications, but many do not. For those that who don't have anyone to come get their medications, or who have had their license taken away, they often feel hopeless like they don't have a way to take their medications, when this is not the case.

Many pharmacies are implementing systems that allow medications to be taken to patients-whether they're patients with disabilities or just patients who would rather have their medications delivered to them. Depending on the prescription volume of the pharmacy the pharmacy will either hire a delivery service to come to their pharmacy and deliver the medications to the patients, or one of the technicians will take their medications to them. At our pharmacy we have one of the technicians deliver medications to not only different nursing home style facilities, elderly patients at their apartments, but also to ACT, the testing station. Many of the patients at ACT have busy schedules and so our pharmacy has came up with a system to deliver their medications to them. All of the patients from ACT have charge cards that they have kept on file with us, and every week we go through the books and on either Tuesday or Thursday we deliver to these patients. Along with charging these medications to their cards, we have to make sure that we remove all of their patient information from the outside of the packages so that we don't violate HIPAA. Along with this we have to have a general signature slide that the main boss at ACT signs allowing their medications to be distributed.

When we deliver to different places such as WestBranch facilities, we have to ring a buzzer to be let into the home, and then the nurses either take the medications from us, or we take their medications to their room. So this way many elderly patients are taking their medications and not skipping doses, increasing compliance and decreasing their chance for having polypharmacy and increased adverse reactions and unwanted side effects. The problem is, many of these patients are unaware that having their medications delivered to them is even an option. Pharmacies need to make sure that they are advertising their delivery services sot hat these patients don't think that they are hopeless, this will not only help the patients but help the service of the pharmacy.

ABN forms

This past week a fragile elderly lady came into the pharmacy with a prescription for a front-wheeled walker, assuming that if she handed us the prescription we would just run the prescription through the computer like all her other medications and have her on her way in less than ten minutes. With durable medical equipment, better referred to in the pharmacy world as DME the process is not so simple. There is a plethora of different forms that need filled out, along with proof of insurance, on top of about 500 signatures that are required from the patient, and even after all this is done, it isn't guaranteed that the patients DME that they're getting will be covered. So why do these patients have to go through the hassle of filing for paperwork anyway? Medicare requires that these patients fill out this paperwork before they can receive their DME supplies. These patients are then required to fill out what is known as an ABN form. An ABN form stands for Advance Beneficiary Notice and the actual form can be found here :

http://www.dbhds.virginia.gov/documents/manuals/OCAR-CommunityReimbursementAppendixA.pdf

This is one example of a form that is commonly seen in community pharmacy practice. What is required is the reason that they are getting the prescription, along with the estimated cost of the product in case medicare decides not to cover the product, the name and information of the patient, along with their diagnosis. There is then a section for the patient to say that yes they want to receive the product or no they do not. There is also in the yes section an option that says if medicare does not cover these products they know that they are to pay the wholesaler price that was quoted to them when they picked up the product. These patients will get to take the product with them that day, and then they will receive a letter in the mail within a couple weeks from medicare letting them know whether or not they were eligible for coverage; the pharmacy also receives this product so that they can not only keep it for their records but that they can make sure that if it is not covered they get paid for their item.

Other items that are considered DME can be anything from Breast Pumps, Nebulizers, Crutches, Diabetic shoes, canes, raised toilet seats and others.

These patients will then have a folder that is kept at the pharmacy for proof of their purchase in case medicare were to audit them and ask for this information. Medicare limits coverage of certain items and services by the diagnosis. If the diagnosis on the claim is not one that Medicare covers for the item or service, Medicare will deny the claim. Many patients will be upset knowing this but it's under the control of Medicare and Medicaid services and not the pharmacy, but make sure that you are very empathetic when working with these patients, because finding out that medicare isn't going to cover something that they see as essential can be a tough time. Also from the pharmacy stand point when they are entering the prescription into the computer they need to make sure that they are using the diagnosis codes that they were given, or else medicare will not recognize the claim and reject it. So knowing all of this it is very important that not only the pharmacists but the technicians are aware of what all goes into working with these ABN forms and how they need to be  dealt with to make the experience the best they can for the patient.

More detailed information can be found at the following location:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

The Importance of Counseling on Inhalers

This week at the pharmacy a woman came in all upset, so upset that she could hardly tell us what was going on. When we finally helped her to settle down, she let us know that she had just gotten off the phone with the Poison Control Center. She stated that she didn't believe what they had told her and wanted a confirmation from the pharmacy staff. This right here shows how much patients use pharmacist as one of their first sources for drug information and knowledge. They trust their pharmacists as much if not more than their doctors. Her concern was that she had just recently been prescribed a Spiriva inhaler, and she had swallowed the capsule that comes with the handihaler. How Spiriva works, is you take the capsule and insert it into the handihaler that comes with the 30 capsules. You put it into the center holder and then close the lid, and wait for a clicking noise. This will puncture the capsule which will then release the powder that was held within the capsule. This releases the powder, and the patient should then breathe out, hold the handihaler vertical to their mouth and breathe in slowly and deeply. This will then cause a vibrating and spinning noise within the machine, moving the capsule shell and inhaling the powder. Hold you breath for ten seconds and then breathe out. Also if you then look inside the container and there is still powder remaining within, you should breathe in a second time to try and get the remaining contents as well. Then open the lid, discard the capsule shell, and clean out the handihaler.

These are all counseling points that should be told to the patient when they're receiving their handihaler for the first time, because patients will not necessarily understand how these devices work. All inhalers work differently, there are metered dose inhalers, breath actuated inhalers, nebulizers, and dry powder inhalers. So being sure to counsel your patient on these different types of devices is very important. Active learning when counseling patients about their inhalers is very important, and can actually determine how well they understand what you're telling them. Instead of just telling them the specifics of how to use the inhaler let them hold the device themselves and walk through the motions. This will better help them remember what they've just learned. The same can be said for other medical devices as well, such as blood glucose meters, lancing devices, nebulizers, breast pumps, nuvarings, suppositories, and other medical delivery systems that stray from the usual tablet or capsule.

Had this patient receiving more in depth counseling she would have known not to swallow the capsule, and to use it properly, avoiding the wasted time, and the scare that she received wondering if she'd be okay after swallowing the capsule. The lesson here is to make sure that we never assume that patients understand how their medications work/should be taken just because they say they do, many times they just want to get out of the pharmacy as fast as they can, or don't want to feel uncomfortable or illiterate if they don't understand. So making sure to just go through this with them is very important, and can save them trouble in the long run.

Geriatric Pharmacy Practice

The field of geriatric pharmacy practice centers around relationships between the geriatric pharmacist—also known as a consultant pharmacist—and their patients. These pharmacists are trained to work with a specialized patient population where they are strictly counseling and handling the medications of older patients. Geriatric pharmacy practice deviates from normal pharmacy practice in that many of these geriatric pharmacists are not actually dispensing medications, but working specifically as the role of a consultant for a team of healthcare professionals, helping to care for these older patients. Most geriatric pharmacy practice settings include nursing homes, assisted living programs, hospice, long-term care facilities, and other locations as well. However, geriatric pharmacy practice is becoming more common in retail pharmacies as well, helping to better aid patients long before they reach the previously mentioned typical geriatric care settings. The number one goal of geriatric pharmacy practice is to make sure that the elderly are being well educated on their medications, receiving the best medication management and therapy available to overall better their health, while tailoring services to best fit the needs of the patients. The demand for geriatric pharmacists is one that is currently growing as the “Baby boomer” generation continues to age, and this type of pharmacy practice can require additional training and education to provide the patients with the best care possible. According to the Center for Human Services, Bureau of Health Professions, pharmacists who wish to focus their area of expertise on geriatrics should be well educated in the needs of older adults, be able to understand different aspects of aging and care, and take on new methods of patient centered care specializing in geriatrics and gerontology. The following is a video clip showing the role of a geriatric pharmacist: http://www.youtube.com/watch?v=Z-7ic197sUc.

“Geriatric Pharmacist.” Institute for Oral Health, 16 Feb. 2012. 27 Feb. 2012. <http://explorehealthcareers.org/en/Career/166/Geriatric_Pharmacist>.

Peggy S. Odegard, PharmD, et al. “Geriatric Pharmacy Education: A Strategic Plan for the Future.” PubMed Central: American Journal of Pharmaceutical Education, 15 June. 2007. Volume 71. 27 Feb 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913301/>.

Because of the arising geriatric patient population there has recently been a new publication put out for many different healthcare workers to read through to be able to better help their patients.  It's referred to as the "Communicating With Older Adults: An Evidence-Based Review of What Really Works" 

This publication will better help healthcare professionals be able to relate to their clientele and also understand what they're going through. "It covers the full range of communication issues experienced by older adults and health care providers, and gives concrete suggestions for dealing with problems when they arise."  (Harwood).

Travel Vaccinations

So you want to study abroad, travel to another country on vacation, do some missionary work, or even just travel the world, what should you worry about other than what to pack and when you should get your passport? One of the biggest issues that people should be concerned with when they're planning an overseas trip to somewhere foreign whether it be to the jungles of Africa, to the deserts of Egypt, or any other country is the issue of what vaccinations they should get before they leave the country. Many questions that they should be forming in their minds before they leave are:

• What are the potential risks of going to this country that I could encounter?
• What hazards to they have in their country that we don't usually worry about in ours?
• Do they have the same schedules and regulations for vaccinations that we have here?
• Who do I talk to about what vaccines I need? 
• How much will these vaccines cost and are they covered by insurance?
• Do the benefits outweigh the risks?

Many of these questions are easily answered by what we now refer to as Travel Clinics. Although finding out what vaccinations you'd need to travel to another country can be done by your doctor, we all know how much of a hassle it is to try and get in to see your doctor, not to mention that there will probably be an $80.00 fee just for having to make an appointment in the first place, even if it is covered by insurance. So what other option is there? Travel clinics, many of which are now located within the pharmacy are becoming more and more popular between frequent travelers. The pharmacy that I work at (Hy-Vee) has a registered pharmacist who is licensed and has passed all the necessary certification needed to be able to conduct travel vaccination sessions. There is a $25.00 session fee for the pharmacist to go over when to set up the appointment to get your vaccinations, what vaccinations you should get, the information about the medications that you will be receiving, and also other facts such as what to stay away from in the country you'll be visiting.

Many of the travel counsel patients that we see at our pharmacy are men and women who are being deployed overseas  and also different students who are going to study abroad in different countries.  So when you find out that you're going to be traveling to somewhere when is a good time to start thinking about this?

Usually at least 4 to 6 weeks before you plan to leave the country you should try to contact your travel clinic to set up an appointment. That way you'll have plenty of time to get prescriptions from your doctor for the shots that you need-which can be taken over the phone by the pharmacist-and set up different times to get the required shots that you need as well. 

In general what vaccinations are usually required? 

Well it definitely depends on what area you're going to, and this can be dependent on many different physiological factors as well. Yellow fever vaccination is always required when traveling to or from different countries-the majority of which is Africa. Other vaccinations are usually recommended by the US CDC depending on where you go, along with these other contributing factors: 

1. Do you plan to visit rural areas?
2. What season will you be traveling in there?
3. Your age
4. Health Status
5. What vaccinations you've had previously

So with regards to the last fact statement there, what vaccinations you've previously had, this means that you should make sure that you're up to date with all your current vaccinations, had all your boosters, and get the recommended vaccinations for your country as well. 

Once you've decided what shots you're going to be receiving and knowing what days you'll be receiving them there's always the question of: what is this going to cost me?

That part is then discovered by your pharmacy, where they run the prescription for the vaccination like any other regular prescription and they submit the claim to your insurance company who will either reject the claim, or pay for the claim. It all is dependent on what kind of insurance you've signed up for, and whether or not that insurance company covers travel vaccines, many of which do not. So what are ball park ranges for prices if I don't get covered?

These prices can range anywhere from less than $100.00 to over $1,000 all depending on how many vaccinations you're getting, and what type of vaccinations you're getting. For patients that aren't covered the cost for a usual travel vaccinations at the clinic includes: 

• Consultation fee $25.00
• A shot administration fee anywhere from $5.00 to $15.00 (per shot in some pharmacies)
•  And the cost of the actual vaccine itself which usually range from less than $10 per dose up to $150 or more per dose, depending on what disease state you're trying to prevent, and many of these vaccinations require multiple injections spanned over a few weeks.

Being able to prepare for traveling to another country is more than just knowing that you've packed your sunscreen and a toothbrush, its knowing that you're doing everything you can to prevent harm to yourself by being in a location that you're not used to. 

Extreme Couponing

A typical scenario that I encounter in retail pharmacy regularly goes something like this: patient comes up to the counter, lets me know that they have a new prescription to drop off, they would like to pick it up at certain time, and I get working on it. Easy enough. But more often than not lately the scenario goes a little more like this: patient comes up to the counter, they have a new prescription, they'd like to come back at a certain time, but ALSO, they have a coupon for the new medication that they have been prescribed. Many of the coupons that I have been seeing lately include ones for Suprep bowel kits for patients who are going to be receiving colonoscopies, Lipitor drug cards, Finacea drug cards, Accutane and Clarvis drug cards, Benicar drug cards, Vyvanse drug cards and other CII drugs, Androgel pump drug cards, and many many others. Where are these patients getting these coupons? They're getting them from multiple different sources actually, including:

• Mainly their doctors when they get a new prescription, and where do the doctors get them from? From their drug representatives 
• From drug stands at the doctors office
• Magazines
• Mail
• See different ads on television for them
• Internet and others

So what's the problem? These patients are just trying to save money on their new prescriptions, so it's a good deal for them. Well actually there are many different problems that these coupons can cause, and most of them unfortunately are cost-based. One of the first problems that the technicians and pharmacists encounter with these coupons is that many times they actually DON'T benefit the patient more than their insurance already does, but for many of the coupons or drug cards they act as a form of secondary insurance, picking up whatever the primary doesn't cover. Another way that many of these cards work is by giving the patient a "maximum" dollar amount that they will have to pay, like with the Lipitor drug cards their selling point is, "Pay NO more than $4.00 for your Lipitor prescription!" Which for anyone in retail pharmacy they know that Lipitor is rather expensive with or without insurance, but there's a generic available. Which then leads to another question and problem, if there is a generic available, and no DAW code written on the prescription, then why are the patient and the Doctor wanting the brand name drug? The main reason behind this is the generic is cheaper than the generic, but not necessarily with that coupon or drug card that they have brought into the pharmacy. If the generic is usually $7.00 a month and they can get it for $4.00 a month, they're going to opt for the cheaper option obviously. But what does that mean for pharmacies and insurance companies, and in the long run, unbeknownst to the patient, the patient themselves. First off the pharmacies, the pharmacy is going to most likely lose money by using this drug card because of their average wholesale price. They're most likely paying a certain dollar amount from the warehouse they get their medications ordered from, and they charge a set amount, which their cost to the customer usually covers. However, when patients use these drug cards it lowers their usual cost and the pharmacy ends up losing anywhere from $3.00 to $80.00 or even more. So by letting these customers use these drug cards we're actually losing money per customer, which adds up, regardless of whether or not they have other medications that they pay full price for. So then the question sadly becomes, is their service worth it? Should we continue to let these customers come to the pharmacy? Would the pharmacy rather have the clientele or save money that they could then use to hire another technician? The next thing to think about is the insurance companies, which in turn by having these coupons given out are losing money to each patient who chooses to use a coupon or drug card. And how do they decide to fix this problem? By increasing the customers premiums, and in the long run charging them more each year, so in many cases the customer is not actually saving money by using these coupons but paying more at the end of each year. So what are pharmacies to do? Turn down the customer if they try to use a coupon and lose the business? No, that's not a reasonable approach, but neither is pumping out large amounts of coupons for medications that could easily be replaced with generics or paid for in general. Many doctors get these coupons from their drug representatives who are trying to get their products out onto the market, and they're usually brand name expensive drugs, not to mention doctors will give these medications out to their patients when they don't know enough about them. So until the insurance companies, pharmacies, doctors offices, and drug reps come to a consensus on how they're going to use these coupons and when it benefits the customer and companies to use these, we're going to continue using and spending money where it shouldn't be spent.

Information about drug coupon use and insurance companies can be found at :
http://www.kaiserhealthnews.org/stories/2012/october/02/drug-coupons.aspx?referrer=search

Probiotics the intestines best friend.

One of the many different products that is sold at my pharmacy on a weekly basis with a wide age range of female customers spanning from young children to adult older women, is Florajen probiotics, which come in three different types. Florajen, better known as acidophilus is a probiotic that is widely used within the pharmacy world today. Different trade names include some of the following:
; Bulgaricum IB^®
 DDS-Acidophilus^®
 Acidophilus Extra Strength
 Intestinex^®
Lactinex^®
Probiata^®
Super Vegi-dophilus^®   

these are only some of the different names for these probiotics, but of these Florajen is the one that I see the most widely dispensed from my pharmacy. So what is acidophilus? The many women of the general public come into the pharmacy hearing their girlfriends and other mothers talk about this product for their children, but they have no idea how it works, they only know to come in and ask for the "good bacteria" having no other knowledge of what this drug can do for them. 

Acidophilus by lex-comp definition is:  A bacterium that creates an environment unfavorable to the overgrowth of potentially pathogenic fungi and bacteria. 

Its two main uses are to aid in cleaning up and protecting the intestinal tract, use for diarrhea, and also for bacterial vaginosis. 

          Bacterial vaginosis, is a vaginal infection that occurs due to an imbalance or change from the normal balance of normal bacteria occurring in the vagina, allowing for different disease-causing bacteria, primarily Gardnerella vaginalis, to overgrow.

Florajen is generally very well tolerated, and can be taken orally, usually with a full glass of milk, juice, or water. It is dispensed as capsules, tablets, and different types of granules that can either be chewed or swallowed whole depending on the composition. 

There are three different products that are currently available by Florajen and those include: Florajen, Florajen 3--which is Florajen's general active ingredients and higher potency composed of three different types of bacteria, and Florajen4kids, which is recommended for normal bacterial growth in children. 

Florajen itself is used for aiding healthy bacterial growth in the intestinal tract along with promoting a health immune system. 

Florajen3 does the same thing but also has an additive effect of helping patients who have bacterial vaginosis as well. 

And then Florajen4kids has a 4 bacterial component makeup that can help children's immune systems and gastrointestinal tracts flourish. 

The majority of these products are supplied as capsules and need to be refrigerated due to stability issues, they come in bottles ranging from 30 to 60 capsules. So why do we recommend this product to many of our female patients and to their children as well? There are quite a few reasons that can be found directly from the products websites, that help to encourage our patients to buy these products. 

Safe and Natural

The micro-organisms in Florajen probiotics are the same “good bacteria” that occur naturally in healthy people. Florajen contains the same strain of Lactobacillus acidophilus used by most yogurt companies in the United States since 1973, yet it is dairy-free.

Highly Potent and Effective

Research has shown that to be effective, probiotic supplements must contain billions of live cells. While many off-the-shelf probiotics fall far short of this standard, each Florajen capsule contains over 20 billion live cells.

Refrigerated for Freshness and Potency

Continuous refrigeration maintains Florajen’s freshness and high potency from the time it is manufactured to the time it is purchased. Look for Florajen in the refrigerated section of your healthfood store or ask your pharmacist.

Guaranteed High Quality

Florajen probiotics are 100% U.S. manufactured in GMP certified facilities. Alll product lot numbers are microbiologically tested for quality and safety according to current FDA and USP procedures and guidelines.

All Florajen products have a money-back guarantee if you are not satisfied with them for any reason.

Affordable

Florajen probiotics provide more live cultures at a lower price than competitive products, making them a better value. Our founder believes that everyone should be able to afford the benefits of high quality probiotics and is priced accordingly.

^{**obtained from} http://www.florajen.com/products.shtml

These products are generally well tolerated, but shouldn't be used in patients who have intestinal disease, GI troubles, or who have intolerance to milk products, but they're regularly not problematic. Overall they can help to keep a normal daily balance of "good bacteria" along with increasing health and stimulating the immune system. So probiotics are good recommendation along with other health supplements like vitamins, to make to your patients.

All out of Prilosec, again?

It happens every week, people coming up to the counter and asking, "Is your store all out of Prilosec? Do I have to have a prescription for it now? Where can I find some? Can you Order an of this in for me?"

Over the last couple of years along with all of the other drug shortages that have been occurring around the world Prilosec OTC is one of the main ones that is brought to my attention at the pharmacy counter weekly.
Procter and Gamble which dispense and manufacture the product have been saying time and time again that these shortages will stop, giving future dates that always get extended. Procter & Gamble and their business partners at AstraZeneca, say they have underestimated demand for the drug and are working to increase production and correct the shortage, but what does that mean for the general public who are trying to save money on expensive prescription medications like Nexium? Well there are many different over the counter products they could use in place of Prilosec, such as the generic Omeprazole which is placed on either side of the empty Prilosec shelves in many stores, and yet people won't trust switching. They say that this is the product they've always been using and the only thing that works for them, when the Omeprazole active ingredients are printed directly on the Prilosec box showing that they are indeed the same drug, and bio-equivalent, not to mention much cheaper.

"America's frequent heartburn problem has been much more frequent than we could have ever predicted," said Kurt Weingand, a spokesman for Procter & Gamble. 
With the majority of Americans in America having problems with acid reflux it's no wonder that the shelves are laying empty at major chain pharmacies and drug stores. 

So what's the hold up on mass producing more prilosec? 
In different featured news articles there is much talk about how Astrazeneca could be pumping out pills right and left, and yet they aren't, and customers of the public are left to wonder, why? It could indeed be due to the fact that the shortage of Prilosec had been good for AstraZeneca because it had increased sales of Nexium, a more expensive prescription heartburn medicine that AstraZeneca markets as well. 
With patients worrying about their usual medications not being on the shelves, they're wasting money to make doctor's appointments, and their doctors are prescribing different medications to tide them over, such as Nexium, which without insurance can be as costly as $5 dollars per pill, and for most Americans who are taking it once daily, that's $150 dollars a month, compared to the $24.99 price of prilosec, and $19.99 box of Omeprazole 28 count box. 

So what are these people to do? As a pharmacy intern and student at our pharmacy I've been watching our pharmacists substitute different products when we're short on prilosec and advising them if they don't want to substitute to ask their doctor or primary care physician what they think that they should be taking to help fight the burn. Although this was an even larger problem back in 2003-2006 it is still occurring quite often today in many community pharmacies around the united states, and causes many people to waste time and money. 


*picture from schmidtlaw.com

"The #1 miracle in a bottle to burn your fat."

My post for this week focuses around a topic that has been brought to my attention quite frequently over the past few weeks at the community pharmacy I work at, and that is the topic of Raspberry Ketones. When I first took a phone call from a customer asking if our store carried Raspberry ketones, I was a bit lost because I had never heard of such a thing, until the patient told me that she had heard about them on Doctor Oz. Doctor Oz stated on one of his episodes that Raspberry Ketones are, "The #1 miracle in a bottle to burn your fat." Having never watched Dr. Oz and only having heard about him recently I wasn't sure whether or not he was trustworthy or even a valid source of information, so I talked with my pharmacist about it, and then looked up raspberry ketones to let other patients know the pro's and con's of taking them.

Once Dr. Oz announced this on his show, vitamin stores everywhere started to increase their inventory on this product, and had a hard time keeping it in stock with everyone wanting to by them.

So what are Raspberry Ketones? They're one of the compounds in raspberries and include anthocyanins, vitamin C and beta carotene, along with being an antioxidant. Their chemical structures are very similar to that of synephrine and capsicum which are two main ingredients in many weight loss drugs, and probably why chemists and doctors correlate this new product to weight loss.

The following article talks about the episode of Dr. Oz and goes on to tell the different studies that he based his information off of.

http://supplement-geek.com/raspberry-ketones-weight-loss-review-side-effects/

Many different websites are leading patients astray saying that raspberry ketones suppress appetite, when there is really no clinical research and studies done to prove this, and yet people are eating it up.
Some other false statements that are in the media are that these can boost your total daily energy, and even decrease the rate of aging, again backed by no research.
Other facts: Raspberry Ketone vitamins contain increased caffeine doses and can be contraindicated in some people.

The information that people should be looking at is this:

"When given to mice in very high doses (up to 2% of body weight), raspberry ketone has been shown to prevent high-fat-diet-induced elevations in body weight^. However, no effects on body weight were observed with doses up to 200 times greater than the estimated intake in humans.The high dose effect is reported to stem from the alteration of lipid metabolism, increasing norepinephrine induced fat breakdown. Although products containing this compound are marketed for weight loss, there is no clinical evidence for this effect in humans."


So when my patients come into the pharmacy asking about these raspberry ketones I'm going to give them the option but let them know that there is no clinical significance that this actually do produce weight loss in humans and that there are many more efficient routes that they can take, not to mention less expensive.

 

Introductory Post/ Modern Health Information Technology

My name's Ashley Thompson and I'm a P2 student this year. I've worked in a community pharmacy for the past 6, going on 7 years and am nearly positive that this is the area of pharmacy practice that I'll be going into after graduation. For my blog I will mostly post about current topics that are going on in the pharmacy world, and how I think that they apply to the community pharmacy setting. 

I thought the following article was appropriate for this weeks discussion on information technology and how it will effect the pharmaceutical field in the future. 

http://www.modernhealthcare.com/article/20120903/INFO/309039976/young-tech-savvy-docs-want-a-real-life-but-dont-call-them-slackers#

This article discusses how many young residents and new doctors are switching from paper charts and files to electronic patient profiles and information. They can more readily access their charts, drug information, and have difficult drug calculation tools at their fingertips.

One of the doctors even said that he couldn't imagine doing his job without his Ipad anymore. With the constant creation of new apps being put out onto the web, the younger generation has unlimited opportunities and helpful tools whenever they need them. These two different doctors in the article stated that they used the smartphones and ipads every day, and yet it didn't mean that they were slacking off or giving less patient care than they would if they still used older methods.

 "These doctors embrace technology and teamwork. They like electronic medical records and smartphone apps. And they like sharing the load with other doctors on the team."

Not only did they say that this was a more efficient way to care for their patients, but it also allowed them to have more free time to do other things outside of the busy life of the hospital, and I would have to agree. 

I believe that this also applies to retail pharmacy because you are frequently being asked drug information questions, and complicated information by your patients, and your job as a pharmacist is to be confident in the information that you're supplying your patient with. By having quick and easy access to different drug information sites such as micromedex and lexicomp, you can rest assured that your patients will not only be getting quality information, but they won't have to extend their stay at the pharmacy to get it. Most customers don't want to be at the pharmacy for long, they're expecting quick service, and if they want information about a drug what quicker way to provide that information than by having your tablet, ipad, or smartphone on you at all times? 

One of the concerns people have with this however, is that people will rely too heavily on the information they can look up, and won't have as extensive knowledge about the practice as pharmacists had in the past, which I disagree with. To be able to get the best use out of these different applications, one has to know what they're looking for, what sites to use for the best results, and the quickest way to go about searching for the answer.Being able to interpret the information you're given and translate it into something the patient will understand is still just as important, whether you're looking up the information in a large reference book, or on an easily accessible website. It's also much easier to show the patient the information that you found to be able to back up your search, and let them see for themselves.

As with our class discussion this week, I believe that either a tablet or a smartphone would be practical for the community setting, however a smartphone would probably be easier to carry with you, seeing as it would fit into your coat pocket. More and more these different forms of technology are entering the pharmacy world and expanding the field of practice. I don't currently own a smartphone or an Ipad, but I know that when I'm on my fourth year rotations I will definitely have one or both of these, and that it will only help me to better communicate with not only my patients, but my team members as well.