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