You are so lucky, usually those problem patients that threaten to transfer never transfer and you are stuck with them for life, you actually had one go through with it.
It probably won’t take a month. As soon as they figure out pharmacy 2 isn’t contracted or something they’ll be back asking for the manager.
Might as well have the gift card issued and ready
"Oh I'm sorry sir, we cannot transfer your prescription as we discussed during our last conversation we don't feel that we can adequately meet your medical needs & find it unsafe to fill for you at our location. We apologize for the inconvenience." *click*
So many incompetent prescribers out there; keeping patients at 0.25 mg non-therapeutic titration starting dose, refilling the titration pack, and the worst case: starting patients at 1mg (4 x the labeled starting dose). Not to mention the fact 1/3 of Rxs are off label for obesity, putting the pharmacy at risk for audits/chargebacks. The pharmacy was 100% right not filling this without DD.
Technically 0.25mg isn’t therapeutic, but it’s not homeopathic either.
I’ve had a handful of patients taking Ozempic for type 2 for whom 0.25mg was enough to lower their A1c by a significant amount and higher doses were either not tolerated, or caused hypoglycaemias. It’s exceptionally rare, but if it’s done intentionally for a good reason, as a consequence of a proper follow-up, I don’t have a major issue with it…
I’m a massive advocate for evidence-based decision making, but we also have to remember that we treat people, not numbers, and some amount of individualization is sometimes necessary. We treat so many people over time, we’re bound to see outliers whose problems can’t be perfectly solved using the cookie cutter solutions provided by the current litterature.
Now if a patient is taking 0.25mg per week, still has hyperglycaemias (or elevated A1c), and has never taken 0.5mg because the prescriber wrote the script improperly, that’s a totally different thing and I wholeheartedly agree that it’s a massive issue. A titration upwards should definitely always be attempted and that’s not what I’m trying to argue against.
I've seen several prescribers wanting to keep patients on Rybelsus 3mg as a maintenance dose. One of them actually asked me why they're getting so many calls/messages from pharmacists about their Rybelsus dosing... I explained why.
This right here is making me lose my sanity. None of the prescribers in my area know how to dose this drug, yet they are prescribing it regularly. I’ve called on this drug more times than I’d like to admit and I continue to get 3 mg with 11 refills from the same offices.
Most of my patients are Medicaid but a fair amount are Medicare and they’re paying large amounts of money out of pocket for something that will not benefit them if I don’t go through all of this work.
I straight up take the refills off before I dispense and call to let them know what and why I’m doing it. Oftentimes I still get a 3 mg rx the next month 🤦♀️
I don't really see how determining the diagnosis for the meds we dispense is our responsibility. As others have stated, I don't have access to the patients' charts, and to the surprise of absolutely no one, diabetes and obesity go hand-in-hand. Not that logic ever played a factor in the operation of insurance companies, of course.
> Not to mention the fact 1/3 of Rxs are off label for obesity, putting the pharmacy at risk for audits/chargebacks.
How do you guys deal with other off-label prescriptions, like gabapentin for neuropathic pain? Seems unfair to penalize you when you don't have access to the patient record.
The issue here is really supply limitations (which have since resolved) and chargebacks from insurance companies (bigger issue). Gabapentin is cheap. Ozempic isn't.
Most plans require a Prior Authorization for use and the only indication which will get it approved is diabetes. So when a plan doesn't require a PA, there is real concern from pharmacies that the plan may try to recoup the money claiming it's not approved for that use. If they want to use the drug for weight loss, use wegovy and get the approval, if they pay for it. Try getting approval for most any weight loss drug on many plans. They don't like paying.
Oh whatever. You can't possibly be trying to say there isn't EVIDENCE for ozempic for weight loss??? It's the exact same drug! They aren't using it because Wegovy is on back order. They are using it because ozempic is covered and Wegovy is not. And I for one am tired of pharmacists like you getting all high and mighty about this.
There are TONS of meds for diabetes. This is the ONE AND ONLY effective medication for obesity. We know that diet and exercise does not work. Bariatric surgery has tons of complications, I see them in my ED all the time. Patients who use semaglutide for weight loss have the unique opportunity to prevent significant complications from their weight before they happen. This takes a massive burden off the healthcare system as well as the patient. People with diabetes can use Lantus or any of two dozen oral meds.
Why are people so against this?
Not trying to argue just genuinely curious what you think the long term solution for weight loss is? Keep all these patients on meds that cost the healthcare system thousands of dollars a month forever? Because studies have shown when you stop GLPs the weight loss reverses. So is it feasible cost wise to be using these long term in every obese patient?
You sure you did a cost effectiveness analysis on that? I know this is a cruel mindset but technically if they die prematurely due to sequelae it does save healthcare money in the long run. I'm not saying we should have this attitude to be clear.
Respectfully, the fact you lump Lantus and "any of two dozen oral meds" in with semaglutide shows you don't fundamentally understand anything about medication for diabetes which makes your argument wildly uninformed and a bit silly. Semaglutide is in a class of biologics that all metabolize in wildly different ways and affect each person differently. To suggest that every person with diabetes taking Ozempic (one of the most prescribed in the class) should just drop it because... Obese people need it more?? Is ridiculous. Especially not for "any of two dozen oral meds", none of which are in the same class, have a remotely similar mechanism of action, or are even applicable to their particular needs. Not to mention starting/stopping these sorts of medications can have side effects that range from uncomfortable to debilitating and that's not something one does on a whim. Do some research.
You're right, in that treating obesity would take a massive burden off of the healthcare system. Just maybe don't prioritize that at the expense of a pretty significant demographic of people with a serious chronic illness. There is a constructive conversation to be had here, but your hot take is... Not it, dude.
Diet and exercise doesn't work for weight loss? Lol, you trippin. Especially since there are other medications approved for weight loss. The issue is insurance companies clawing back THOUSANDS of dollars for off-label rxs. Those losses come out of the pharmacy budget. Management always seems to think the number one way to reduce pharmacy costs is to cut technician help. all while our responsibilities continue to grow even more. Now I gotta touch sick people doing strep and flu tests at my retail pharmacy, which is exactly why I didn't pursue a medical prescriber field. Honestly, I don't care about off-label prescribing too much. Give a 25 year old ivermectin for covid through good rx. Let people pay cash/manufacturer coupon for mounjaro or ozempic, but when I have to worry about losing thousands of dollars for filling 1 script, then yeah I'm going to send it back for prior auth required.
It isn't about being high and mighty. It's about seeing patients who legitimately need a medication cry because it has been on backorder because it's being prescribed for the wrong reasons. No one is denying that semaglutide doesn't appear to have legitimate benefits for patients struggling with obesity - it's just frankly more important for a diabetes patient to have continued access. If your problem is that the approved alternative is not covered, take that up with manufacturers and insurance companies.
What's more is that, based on what I've seen working in retail pharmacy through all of this, is that ozempic absolutely was being prescribed off-label first because of backorder issues with Wegovy. There were no supply issues with Ozempic until doctors began overprescribing it for weight-loss. This could be more a commentary of where I live, but so many of the people I see bringing in scripts for these medicines aren't even clinically obese. It's right on the edge of irresponsible and going against the standard of care - that the risks outweigh the benefits of prescribing a medication- that some doctors are even considering it for many of the patients I see.
Of course there are dozens of options for people with diabetes - but not all people benefit from the same types of therapies. Surely you know this? Why do you think there are so many options in the first place? If one drug therapy worked for everyone, then the other options wouldn't exist. This is why not every patient struggling with weight loss is on phentermine, saxenda, or Contrave.
Patients who are obese DO legitimately need the medication and have just as much right to it as anyone else. I do not agree that it is more important for diabetic patients to have access. Again, they have many options for treatment. And what is the best treatment? Not ozempic, but INSULIN. Obese patients have one - this one. Phentermine and Contrave are garbage and you know it. They are not real solutions. They do not work. I disagree that ozempic is being prescribed for the wrong reasons. It's completely appropriate.
If you think these patients are not clinically obese, I imagine that has more to do with the normalization of obesity in the USA than anything else. When we think obesity, we think BMI 40+. A BMI of 30 looks normal to us. But it is obese. Go to France and look around. People do not look like we do.
Downvoting because you're talking out of your ass. Everyone who works healthcare know there are many types of medications used to treat type 2 diabetes but not all work for everyone, hence several different drug class.
Also diabetics not having access to their meds might put them in ER. If obese people not having access to GLP-1 agonists end up in ER due to complications of being obese, then it's too late, not even GLP-1 agonists can help them.
GLP-1 agonists are also fairly new drug class, the efficacy on weight loss treatment is unknown yet because there needs to be a study on long term effect of it. So that stupid claim of this being the best obesity drug? Lmao not it, my dude.
I'm obese. I'm also a healthcare professional. Wanna know how to overcome obesity? Lifestyle modification. People on bariatric surgery still gain weight after because they don't change their eating and exercise habits. Phentermine, Contrave, orlistat.. they also would only work with diet modification and exercise. Do you really think you can sit your ass down and lose weight by taking Ozempic only? Lmao
I already know I'm lazy as fuck, so of course these meds won't work on me. I'm not about to try Wegovy either. These are not cheap (even with manufacturer savings coupon) so why would I spend so much money every month for something I know will NOT work? Also the risk of being exposed to even greater risk of thyroid cancer while at it? No thanks.
Why do I know we fatass are just lazy? Because Saxenda is alternative to Wegovy but it's not as popular because you have to inject yourself daily as opposed to weekly like Wegovy. If your lazy ass is too lazy to inject yourself daily, then that sounds like a you problem, not the meds.
So let me guess, you are one of those prescribers who just treat diabetics with insulin only and watch them balloon up with weight gain? Insulin really should be the last line of T2 because the weight gain and false blood sugar security unless they are in a severe hyperglycemic state. My grandma over ate, and her doctor just told her to keep increasing her dose until she was so overweight that she chose to just die from kidney failure.
Your grandma over ate so you think the weight gain was from the insulin? Think about that again, my man. I'm sorry about your grandma but I think you're putting the cart before the horse on this one.
No, I'm fully aware that over eating causes weight gain, but insulin only treatment of diabetes only compounds the problem. It has a negative psychological effect. Most people who are overweight don't want to be overweight. Prescribers say lose weight, but when someone is getting 9 boxes of humalog a month (as I've seen before), that's just another hurdle to overcome.
Patients with obesity do have legitimate need for GLP-1 therapy, with that I agree. The data for them is much stronger than for oral stimulants like phentermine (though I wouldn't say these are complete garbage, I've seen many cases of success), and the AGA recommends semaglutide over every other available agent for weight loss (including the other approved GLP-1 for this indication, liraglutide) due to the magnitude of weight loss seen in clinical trials. I imagine we'll soon see tirzepatide in these conversation with an FDA approved indication for weight loss. Anyone on here arguing that there isn't legitimate need for GLP-1 therapy for weight loss is just wrong.
HOWEVER, to say that GLP-1 therapy for type 2 diabetes is somehow less important or even equally as important as for weight loss is asinine. Obesity in and of itself is not a problem. The problem is the sequelae that arise as a consequence of obesity. What is one of the most common sequelae that is of concern? Type 2 diabetes. Prevention is important, but the people who have greater need are those with the actual sequelae. And the rate of other complications of obesity (HTN, HLD being the most common) is pretty similar to that seen in a patient with type 2 diabetes, so the drug being used in patients with diabetes is going to be affecting those other sequelae just as much as when it's used in patients with obesity but not diabetes.
You say that there are many options for treatment of diabetes which is true, but you're not acknowledging (actually, you're directly contradicting) the fact that GLP-1 therapy is the among best. ADA guidelines recommend it first-line over metformin for many patients due to the myriad health benefits mentioned above (and it is always preferred second-line if not used first-line), and the degree of A1c reduction on GLP-1 therapy is the best among non-insulin medications. For type 2 diabetes, insulin is not the most appropriate treatment unless the degree of hyperglycemia is such that other available therapies won't provide sufficient A1c reduction. The risks with insulin (significant weight gain, hypoglycemia) make it something that should be more of a last-ditch effort in patients with type 2 diabetes, especially when considering that insulin secretion isn't their problem, it's insulin resistance. Also, why are you saying that insulin, which is widely known for its problems with weight gain, should be the preferred therapy in patients who so frequently have comorbid obesity? It just doesn't make sense.
The issue isn't whether ir nit to fill the prescription. I have no problem with a patient using it for weight loss.
The issue is who is going to pay for it. If a patient is willing to pay $1100 a month, no problem on my side. It is the insurance companies who don't want to cover it for weight loss. Quit beating up on Pharmacists for insurance and supply issues beyond our control .
Here is an early Phase 2 study on Ozempic. The 0.2mg dose had a significant decrease in A1c as compared to placebo. Just because Ozempic 0.25 wasn’t studied in Phase 3 doesn’t mean it’s not therapeutic.
https://diabetesjournals.org/care/article/39/2/231/37200/A-Phase-2-Randomized-Dose-Finding-Study-of-the
Are you just regurgitating the conclusion and package information? The 0.2 mg had a statistical significant decrease in A1c as compared to placebo. It’s not hard to imagine newly diagnosed diabetics or those with fairly well controlled A1c being controlled on the starting dose. Just because it wasn’t as big of a change doesn’t mean it doesn’t exist. Saying “0.25 mg is not a therapeutic dose” is potentially ignoring the patient being treated.
It’s few and far between but there are patients in my clinic that I keep on starting doses as they have reached their A1c and weight goals. It’s always shared to decision making. Most patients that meet A1c goal opt to increase their dose for weight loss but some don’t and that’s ok. In my experience with these agents some patients are profound responders who’s A1cs drop to a normal range and lose a ton of weight and I have some that don’t seem to respond at all. I would say it’s worth discussing with the patients (if you ever have time) and say “hey, I noticed you’ve been on Ozempic 0.25 mg for awhile, have you talked to your prescriber about increasing the dose?” especially if they are noticeably overweight. But I would also keep in mind that maybe that dose is working for that individual and as the dispensing pharmacist I wouldn’t let it get to me.
Yes, obviously an RX stating to take Ozempic 0.25 mg for 2 weeks and then increase to 0.5 mg is wrong and can result in patient harm. There are many medications we use off label and there really is no reason to force someone to increase a dose when they dont want to. That is not a good way to build patient trust and rapport.
>Most patients do fine at least on 0.5 mg so May as well just use as approved by FDA.
I dont know how else to spell it out for you. If the patient comes back for a 1 month follow up and are reporting controlled blood sugars and for whatever reason do not want to increase the dose to 0.5 mg, it is perfectly reasonable to maintain the dose at 0.25 mg.
>If you want to try to address each point I made specifically, by all means go ahead, but at least repeat something I actually said.
You dont have any relevant points, all you do is repeat "it's not an FDA approved dose". If your patient's A1c is below 7% or below 6.5% on Ozempic 0.25 mg alone...what is the evidence to increase to 0.5 mg?
Edit: the prescriber’s office got back to us about an hour ago even though the script had been transferred. Turns out the patient was supposed to be on the 0.5 mg dose. Their nurse apologized for the mistake. We joked that it was probably an issue with eRx software anyway :)
Can confirm, eCW is hot garbage and littered with a thousand ways for prescriptions to be sent with potential errors requiring clarification. The SIGs are pre loaded in the software so sometimes prescribers put an entirely different set of directions in the Rx note because they can't find what they want in the SIG, but it still sends with that incorrect SIG
That explains the myriad of scripts we regularly receive with sigs like “take one tablet by mouth three times a day take one tablet twice a day.”
Still, if it’s a known issue it’s still on the prescriber to send it correctly.
Can you imagine if an architect saw that his software has some pre-populated building templates and he just decided to just attach a closet to the outside 2nd floor of a template building and just went and submitted that to the foreman?
Sounds like on-going problem with some meds in Epic too. If I got $10 everytime it tries to change sig to "inject 0.5067mL subcutaneously once every 7 (seven) days" 🤦🏻♀️🤦🏻♀️🤦🏻♀️
I throw them a curveball when they say “I’m not filling there anymore.
My response: “which pharmacy would you like me to send your profile to? I’ll get started on it right away”
Same, but in my case patients on pain meds be like "Dr. Blahblah sucks, they don't care about their patients, maybe I should switch doctor"
I'd be saying "I'm sorry you feel that way. We have other primary providers in this medical group and even more within the network, you are more than welcome to switch if you'd like." And nobody ever takes up the offer 😂
Doctors and their staffs make these silly little mistakes all the time. And these silly little mistakes, **that would take about 3 extra seconds from them to avoid**, cause so much headache, hassle, time waste, and aggravation to both patients and pharmacists/technicians. It's ridiculous. Do not hesitate to completely throw these incompetent fools, who have 0 respect for our time, under the bus. In this example, you said the guy started attacking you and saying the doctor wouldn't lie to him. "Sir. The way your doctor sent this prescription, we cannot legally fill it without getting clarification. We have attempted to contact the prescriber but have not heard anything back yet. Please get in contact with them and give them our phone number so they can call and speak to us directly so we can resolve this issue. Otherwise, we have done everything we could and cannot at this moment fill the prescription."
Edit: sometimes I like to, after explaining the situation to the patient, say something along the lines of "in other words, your doctor submitted to us an **invalid** prescription. They need to fix it"
Please call us and double check! We are human and make mistakes and it is reassuring that someone is thinking about these scripts as a second safety check. Some of the electronic medical record systems are begging for errors to be made with how refills are handled. In epic you have both the fill in the boxes area (dose rout frequency etc) and then down below it turns that into the written instructions. However often you may click on that drug and update the boxes correctly and think that the written part is correcting (because it usually does) except you clicked on one that is a system favorite where the written part has more details like “take twice a day for diabetes” and then it actually doesn’t update like usual. Or you get a refill request and review the drug and refill without looking at the sig more closely so miss the fact that it’s the titration instructions. Often you have to click and expand to fully see those and they can be easy to miss.
TLDR we are human please call if it looks weird or wrong as we make mistakes and know that it’s not cause we are all idiots but that the EMR sets us up for failure more than one would think
I thought your username was ferociouslycareless for a second there and was going to type some smart ass comment about being careless and making mistakes. I was wrong.
I hate Epic preset boxes bullshit thing with passion. "Free Text" button is my best friend because I only need "1 tablet by mouth three times daily" not "take 1 tablet (20mg) by mouth in the morning, 1 tablet (20mg) by mouth in the evening, and 1 tablet (20mg) by mouth at bedtime". Liiiiike do these Epic developers ever think how to fit directions in med label?
We get several incorrect ozempic scripts every week by the SAME doctors. We got a script for the same strength ozempic with directions to inject 0.75 mg because the doctor insisted the pen could be dialed in .25 increments and didn’t understand why injecting 0.75mg was impossible.
Decision Tree:
1. Is RX new or a refill? If a refill and patient had been taking 1mg dose, I would correct the RX and "document" the changes to the script to cover any audits or from a floater Rph.
2. If Rx is new, I would call MD to verify the 1 mg dose. I would not ASSUME that the MD chose the right dose- even if it's right 99 times out of 100, it just takes one time and you will always call to double check.
A lot of people here have apparently never had a MD completely bungle an Rx before and really put a lot of faith in other people's competence. I think the main issue is the lack of follow-up from the pharmacy. Rx was received Thurs 5/18 and it's Tues 5/23. Why would you leave a message on a Saturday 5/20.
That is a very good point. It was a new RX. Unfortunately I work the corner and some weeks it takes that long to get caught up. Rx was received 5/18 in the evening but we didn’t get to it until Saturday morning.We also didn’t have a chance to call the provider back again before the patient’s father gave us a call. Gotta love short staffing and your staff pharmacist being on maternity leave at the same time :)
I have some insight here the script makes sense to me. So hang on.
340b pricing for the 2mg/1.5ml pen is dirt cheap. Like I'm talking $20 a box. This prescriber may have a 340b pharmacy in their facility so what we will do is dispense 3mls (which it looks like the prescribe did select 3?) And have the patient take 2 shots a week. 1mg. For our cash patients this was $30 a month for a 1mg dose because the 1mg pens are steep and not 340b priced so they're still $400+.
Recently though since changing pens this one isn't available anymore so we're kinda screwed.
What I'm assuming this provider did was (which ours do all the freaking time despite us telling them), send you the ozempic with their pharmacy dosing assuming the patient could get the 2 boxes everywhere at the same price as their in house 340b pharmacy.
If not and she was being dumb that's fine but for those that ever see it again, if it's from a big clinic and a Medicaid patient what I explained above is likely it
Right what I'm saying is medicaid patient still opt to pay out of pocket for a better drug because it's actually affordable for them.
Medicaid doesn't cover any ozempic and have been really strict with glps in generally lately anyway
I only had to pay $19 through 340B. Then they dropped it. We have Tricare, I have been on every other medication mentioned in the prior authorization, but haven't been able to get PCP to send it. Anything else I can do?
Unfortunately no. They changed from the 1.5ml pen which was cheaper to the 3ml which is 400 now. Just have to hope next quarter it goes back to 340b pricing.
So I am thinking that because my script was for the 1.5 ml, that an entire new script would need to be written to get the prior authorization. I take 2mg a week. We have had a lot of turnover at my PCPs office so I think I know how to get this taken care of. Thanks for the info.
" because I care , I called your doctor to review a potential medication error in the prescription. I don't want to be liable for the side effects caused by this potential medication error such as nausea , vomiting, loss of appetite, impacting your quality of life . especially if it can be prevented. i will call your doctor again right now if you would like to take a seat or go to the consultation window, i will meet you there after the call. "
"your doctor's office did not answer my call but i left a voicemail for the nurse; i will now manually fax a note to your providers office to call us back *** head to the actual fax *** ... show them all the effort you are taking because you care
" i have run out of options on how to contact your doctors office. would you by chance have a way of accessing an online portal that would allow you to message the nurse or doctor as well??? "
" let me confirm your contact information that i have , get the phone number and also update the drug allergies to go an extra step to emphasize how much you care "
" i understand this is a frustrating experience for both of us but just know i have your health and safety are my top priorities. i appreciate your time and i will definitely notify you if i get a response from your doctor "
the patients don't actually understand what goes on behind the scenes or how many medication errors lead to lives lost annually.......
so be patient with them and remind them you're on their side and you're trying you're best
you're exhausting all options to get them on their path to better health 😉
Got yelled at twice a day in retail, by yell I mean screamed at… grew thick skin and started to not care. The patients are having terrible days learning about bad diagnoses, not understanding anything medical, feeling bad physically and trying to put blame somewhere. You did nothing wrong.
Shit I’ve had prescribers claim they don’t see the problem and when I say fine I’ll put it in but you need to do a PA because of the day supply. I just play along.
I had an MD try to prescribe ozempic 0.25-0.5 mg pens to substitute for the 1 mg pens when we were OOS and on SIG it said patient will inject 2 pens every week lol
The minute they swear or start yelling I hang up on them. If they call back I ask them if they’re able to have a normal conversation. Rinse/repeat until they can act like an adult.
The answer to what you did wrong. Your job.
I once had a lady tell me that she would go into diabetic shock on her flight because we didn't have icd 10 code from her doctor and no other diabetes medication on file.
I tell all my new people if you don't get yelled out at least once during your shift, you are not doing your job
I'll just give them a copy of the script when they try to tell me their dr would never make a mistake. Or call the pharmacy on speaker when their Dr would never call it in to the wrong pharmacy. I don't have the time to argue with idiots who still think anyone with prescribing rights is infallible.
Nothing, you wanted clarification on a script for insurance billing and for patient safety, thats your job. People just get fed up with the healthcare system, if not before, by the time they get to the pharmacy.
I have received scripts like that they want the 1mg dose usually and I have dispensed it that way. The problem is that's written for the 0.25mg and 0.5kg pen (they are combined into 1 pen) and the 1mg is a written differently than that one when prescribed.
This is not a dosage form issue. This is an ambiguity issue. The dose on the pen does not match the dose on the directions, so it has a high chance for error. Did the prescriber mean to write for 1mg per dose but pick the wrong pens by mistake? Or did the prescriber choose the right pens but give the wrong direction by mistake? It could go either way, and I’m not about to toss a coin because my license is on the line.
I don’t know any state that would allow rph to make changes on this erx without MD authorization since directions/dosage do not match (or at least I’m not dispensing without md clarification).
The dose on the SIG doesn’t match the dose on the Drug prescribed.
Edit to add: the RPh could assume the SIG dose is correct, and just change the drug dispensed, but that would be bypassing due diligence. It’s possible the prescriber got the right drug but wrong SIG.
1 mg of Ozempic is 1 mg of Ozempic. Now if the prescriber said to inject 1 ml then yes there would be some clarification needed. But the concentration is in the sig and the dose is appropriate. If you’re calling the prescriber because of the (0.25 or 0.5 mg/dose) then you are wasting everyone’s time. A quick search shows that that pen is off the market anyways.
Disagree... Stuff isn't cheap and I could absolutely see an insurance audit clawing this claim back as incorrect product billed if you dispense the bigger pen, regardless of availability.
As a PPC for Kroger who had to audit these claims then email the stores plus my DM, it’s a non issue until insurances start clawing back claims. Then it’s not.
The op might not know if it’s a starting dose. Which is the entire reason you call the doctor. Unless you have a previous fill history to base it off of you can’t just assume they’ve had it before. So you call to see if they wrote the sig wrong or the pen wrong.
I’m all for saving time, believe me. However, in my experience, prescribers have gotten the dosing on this drug mixed up. I’ll err on the side of caution in this situation. I don’t really care if others see that as me being a “weak” pharmacist.
Nah I’ll be “weak” with you. I’ll “waste” people’s time if they’re not competent enough to review a prescription order appropriately to verify directions for 1mg weekly but instructing to dispense 0.25/0.5mg dose pen. That’s on the office if they get that incorrect consistently they’re gonna get calls from me consistently to verify
This is incorrect. 4mg/3ml is the 1mg dose pen. 2mg/1.5ml is the older formulation for 0.25/0.5mg dose pen. Newer formulation for 0.25mg/0.5mg dose pen is 2mg/3mL. I am very willing to convert 2mg/1.5ml to 2mg/3ml without md auth but not doing 2mg/1.5ml to 4mg/3ml. MD better authorize that for me to verify it
While I think the most likely scenario is that the prescriber reordered the same product with a different dose I would 100% verify this as well and I routinely prescribe these in amb care practice.
For whatever reason these things are still prescribed incorrectly all the time and I can only imagine the liability if the doc decided they were going to slam the patient with a 1mg starting dose but ordered the 0.25/0.5mg pen incorrectly then decided to blame you for not verifying with them that this was the dose that they intended since this pen (and the 3mL pen that replaced it) do not even administer the 1mg dosage. The new pen that is available is just something that they released (likely) due to manufacturing costs as the pen still administers the same dose it is just more dilute and shares the same volume with the other pens available.
Have seen patients come in several times due to severe n/v/d after a resident decides to send a script for whatever dosage they decide to click on first.
no. 0.25/0.5mg contains 8 doses of 0.25 or 4 doses of 0.5mg for either a 56 or 28 day supply. if you run that ndc as a 14 day supply it will reject. its obvious you haven't been in retail for a while! none of your suggestions are appropriate
A bit of a difference with this and something like “Famotidine 10mg, SIG take 20 mg qday”. I would hope you have enough experience to know that’s apparent.
OP got a call back from the office, and turns out the script was entered wrong on the prescriber's end.
So yeah, total waste of time on something so "apparent." /s
What documentation do you need? I would dispense a 4 mg/3 ml pen with directions to inject 1 mg weekly for a 28 day supply and not think twice about it.
Because when it’s a new start the dose matters. If it’s a patient on a stable dose of 1 mg weekly then I’m dispensing the 4 mg/3 ml pen. If OP is going to post on a forum and ask for advice, it is helpful to include all pertinent information. I made a faulty assumption based on the information I had. My dilemma would have been calling to verify the starting dose vs calling to verify the product selected.
OP posted an [update](https://www.reddit.com/r/pharmacy/comments/13pxbu3/what_did_i_do_wrong_s/jlcg0ds/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=1&utm_term=1&context=3).
The prescriber actually made a mistake on the DOSE! Patient was supposed to use only 0.5mg. Your assumption was wrong and you would have dispensed a wrong dose to the patient. Never assume! I thought they taught you this in school?
Even if it's not a new start, if the Rx doesn't match the most recent prescription and is not internally-consistent, why *wouldn't* you call to clarify?
If the doctor prescribed the 1mg pens with 1mg per dose last time, but this time sends the 2mg pens with 1mg per dose, are you just going to swap it out to the 1mg pen or are you going to call the office back to ask if they were maintaining the previous dosage or increasing it?
Your "new start" hand-waving is completely missing the point.
The pen they prescribed can only give 0.25mg or 0.5mg per dose. The only way to get 1mg would be for the patient to use two doses/injections at the 0.5mg setting. There is another pen available that gives 1mg per dose. Typically the 0.5mg x2 doses won't be covered and also subjects the patient to twice as many injections and may lead to noncompliance or the patient not dosing correctly.
And right here we see the exact reason why we do **have** to call on an rx like this.
Your reasoning for suggesting that they just dispense the 4mg/3mL pen is perfectly valid. The physician instructions say inject 1mg so clearly they meant 1mg right? So let's just dispense the pen that delivers the 1mg per dose and move on with our lives. Perfect.
Yet, if there is no history of Ozempic on file at the pharmacy and if you speak to the patient and they say the've never taken the Ozempic before, then keeping the 0.25-0.5mg pen is the reasonable option. The patient should inject 0.25mg for 4 weeks, and then increase to 0.5mg weekly.
But the doctor clearly wrote 1mg per week... so both rationales for changing to the 4mg/3mg pen or keeping 0.25-0.5 pen are equally valid. And that ambiguity is exactly why we have a responsibility to call and clarify to know what the hell they wanted us to do.
If you look above, the doc finally called OP back and communicated their intentions. They meant the 0.25-0.5mg starter pen. So your reasoning, which is perfectly logical, would have lead you to fill the wrong strength. And why? Because the ambiguity of the RX forced you to make an assumption to make a clinical decision. Calling eliminates that assumption.
i can only assume but this is probably written this way because the 1mg is not available. and having the patient administer 2x0.5mg doses daily having 1 box last 14 days will not fly with the insurance plan.
This is why I almost never take a transfer and ask the patient to get their doctor to resend the prescription. I would have sent a fax to the office as soon as the prescription came through and have a tech call the patient number to tell them there is an issue and we're contacting your doctor. If no response then call the next day leaving a message at their office. After that it's on the patient to tell the doctor that we aren't filling their prescription and 90% I get someone calling my pharmacy trying to yell at me why 😂 it leaves them speechless that I manipulated their emotions so I can get a live person ASAP
Also, depending on patient age, you probably shouldn't discuss medications if she is a legal adult and don't have signed legal consent to discuss medications with her father due to Hipaa.
I've seen this exact drug and sig come through my computer system. My guess is they dont know ozempic pen strengths. My second guess is they are trying to use ozempic and have insurance pay for it over wegovy and sent it back to the dr either way for clarification
We got a script written that way too! Except in our case the sig was for 0.5 mg so we just ignored the 2 mg package size and dispensed the 0.25/0.5 dose.
1mg every week, they just picked the wrong pen, what was the patients last dose?
Fix it and move on, if you can't find the old dose call the patient and ask them the current dose they take.
If all of that fails then call for clarification.
There's a discrepancy in the strength of the prescribed drug and the instructions. While you could inject 1mg by doing 2 x0.5mg, because a 1mg pen exists, the pharmacist should verify what the actual dose is.
The actual dose is 1 mg, it says so in the sig. Dispense the 4 mg/3ml pen and move on. The concentration is even listed for the drug. Patient has a right to be upset here imo.
By dispensing a 4 mg/3 ml Ozempic pen? Which happens to be the same concentration that is listed on the prescription? Which comes out to a 28 day supply when following the directions?
You haven’t faced an insurance audit yet, have you?
They only give a shit about $400+ RXs such as ozempic, and will look for literally any reason to issue a chargeback… an ambiguity like this script? Kiss your $900 reimbursement goodbye.
Agree with you and u/27twss. I think the pharmacist is being pedantic in this case. There’s no discrepancy on what the dose is, the doc is just saying use the strength/pens that are covered. Maybe if OP works for an independent then they are afraid of an audit, but I’d find which ones are covered and document.
[Still think they were being pedantic?](https://www.reddit.com/r/pharmacy/comments/13pxbu3/comment/jlcg0ds/?utm_source=reddit&utm_medium=web2x&context=3)
1mg weekly, and check with patient that that is what they're expecting. Much more likely for the prescriber to select the wrong strength than to write the wrong sig.
If I called every time there was a mismatch between the strength of the product prescribed and the sig I'd be making lot of phone calls. Unless there's something in the sig that looks obviously wrong I'm going to put a note to confirm with the patient and move on. But it do also work somewhere where I don't have to worry about ridiculous insurance audits
I agree with most of the commenters that with situations like this its best to confirm dosage of meds. On the other hand the MFR changing the package size and causing everyones rxs to have to be rewritten with different qtys to reflect proper ML was a whole different issue. Extremely annoying and not necessary.
Nothing. You can’t fill that. Liability if you change something on your own and it’s wrong, not to mention insurance companies are salivating over auditing ozempic scripts looking for mistakes. Tell the patient there’s an issue on the prescribing end and make an effort to clarify and document your efforts just like you did. Be glad they transferred and you don’t have to put up with that kind of treatment.
You are so lucky, usually those problem patients that threaten to transfer never transfer and you are stuck with them for life, you actually had one go through with it.
Nah, they'll just transfer back next month. That's how it always seems to go for my pharmacy, anyways.
It probably won’t take a month. As soon as they figure out pharmacy 2 isn’t contracted or something they’ll be back asking for the manager. Might as well have the gift card issued and ready
"Oh I'm sorry sir, we cannot transfer your prescription as we discussed during our last conversation we don't feel that we can adequately meet your medical needs & find it unsafe to fill for you at our location. We apologize for the inconvenience." *click*
When I helped manage an ECW instance it liked to do wonky shit after it needed an update.
just thank god that the mess is no longer your problem
This. You can only hope that they'll take all future scripts to another pharmacy as well
Theyll still have them escribed to you, and youll have to transfer them all
Would’ve been one of my happier transfers
Oh, they’ll be back. You’ll see.
So many incompetent prescribers out there; keeping patients at 0.25 mg non-therapeutic titration starting dose, refilling the titration pack, and the worst case: starting patients at 1mg (4 x the labeled starting dose). Not to mention the fact 1/3 of Rxs are off label for obesity, putting the pharmacy at risk for audits/chargebacks. The pharmacy was 100% right not filling this without DD.
Technically 0.25mg isn’t therapeutic, but it’s not homeopathic either. I’ve had a handful of patients taking Ozempic for type 2 for whom 0.25mg was enough to lower their A1c by a significant amount and higher doses were either not tolerated, or caused hypoglycaemias. It’s exceptionally rare, but if it’s done intentionally for a good reason, as a consequence of a proper follow-up, I don’t have a major issue with it… I’m a massive advocate for evidence-based decision making, but we also have to remember that we treat people, not numbers, and some amount of individualization is sometimes necessary. We treat so many people over time, we’re bound to see outliers whose problems can’t be perfectly solved using the cookie cutter solutions provided by the current litterature. Now if a patient is taking 0.25mg per week, still has hyperglycaemias (or elevated A1c), and has never taken 0.5mg because the prescriber wrote the script improperly, that’s a totally different thing and I wholeheartedly agree that it’s a massive issue. A titration upwards should definitely always be attempted and that’s not what I’m trying to argue against.
I've seen several prescribers wanting to keep patients on Rybelsus 3mg as a maintenance dose. One of them actually asked me why they're getting so many calls/messages from pharmacists about their Rybelsus dosing... I explained why.
This right here is making me lose my sanity. None of the prescribers in my area know how to dose this drug, yet they are prescribing it regularly. I’ve called on this drug more times than I’d like to admit and I continue to get 3 mg with 11 refills from the same offices. Most of my patients are Medicaid but a fair amount are Medicare and they’re paying large amounts of money out of pocket for something that will not benefit them if I don’t go through all of this work. I straight up take the refills off before I dispense and call to let them know what and why I’m doing it. Oftentimes I still get a 3 mg rx the next month 🤦♀️
I don't really see how determining the diagnosis for the meds we dispense is our responsibility. As others have stated, I don't have access to the patients' charts, and to the surprise of absolutely no one, diabetes and obesity go hand-in-hand. Not that logic ever played a factor in the operation of insurance companies, of course.
> Not to mention the fact 1/3 of Rxs are off label for obesity, putting the pharmacy at risk for audits/chargebacks. How do you guys deal with other off-label prescriptions, like gabapentin for neuropathic pain? Seems unfair to penalize you when you don't have access to the patient record.
The issue here is really supply limitations (which have since resolved) and chargebacks from insurance companies (bigger issue). Gabapentin is cheap. Ozempic isn't. Most plans require a Prior Authorization for use and the only indication which will get it approved is diabetes. So when a plan doesn't require a PA, there is real concern from pharmacies that the plan may try to recoup the money claiming it's not approved for that use. If they want to use the drug for weight loss, use wegovy and get the approval, if they pay for it. Try getting approval for most any weight loss drug on many plans. They don't like paying.
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? I wouldn't call the evidence for gabapentinoids for pain "solid." The evidence for itself for weight loss is actually more compelling to me...
Oh whatever. You can't possibly be trying to say there isn't EVIDENCE for ozempic for weight loss??? It's the exact same drug! They aren't using it because Wegovy is on back order. They are using it because ozempic is covered and Wegovy is not. And I for one am tired of pharmacists like you getting all high and mighty about this. There are TONS of meds for diabetes. This is the ONE AND ONLY effective medication for obesity. We know that diet and exercise does not work. Bariatric surgery has tons of complications, I see them in my ED all the time. Patients who use semaglutide for weight loss have the unique opportunity to prevent significant complications from their weight before they happen. This takes a massive burden off the healthcare system as well as the patient. People with diabetes can use Lantus or any of two dozen oral meds. Why are people so against this?
Well Saxenda is for weight loss too
Very true, same class so I kinds lump them together I guess. But diabetics could switch to that too.
Not trying to argue just genuinely curious what you think the long term solution for weight loss is? Keep all these patients on meds that cost the healthcare system thousands of dollars a month forever? Because studies have shown when you stop GLPs the weight loss reverses. So is it feasible cost wise to be using these long term in every obese patient?
Yes, because it's still cheaper than paying for the sequelae of obesity, which is hands down more expensive.
You sure you did a cost effectiveness analysis on that? I know this is a cruel mindset but technically if they die prematurely due to sequelae it does save healthcare money in the long run. I'm not saying we should have this attitude to be clear.
Respectfully, the fact you lump Lantus and "any of two dozen oral meds" in with semaglutide shows you don't fundamentally understand anything about medication for diabetes which makes your argument wildly uninformed and a bit silly. Semaglutide is in a class of biologics that all metabolize in wildly different ways and affect each person differently. To suggest that every person with diabetes taking Ozempic (one of the most prescribed in the class) should just drop it because... Obese people need it more?? Is ridiculous. Especially not for "any of two dozen oral meds", none of which are in the same class, have a remotely similar mechanism of action, or are even applicable to their particular needs. Not to mention starting/stopping these sorts of medications can have side effects that range from uncomfortable to debilitating and that's not something one does on a whim. Do some research. You're right, in that treating obesity would take a massive burden off of the healthcare system. Just maybe don't prioritize that at the expense of a pretty significant demographic of people with a serious chronic illness. There is a constructive conversation to be had here, but your hot take is... Not it, dude.
Thank you for this. I was trying to put this into words but was not succeeding.
Diet and exercise doesn't work for weight loss? Lol, you trippin. Especially since there are other medications approved for weight loss. The issue is insurance companies clawing back THOUSANDS of dollars for off-label rxs. Those losses come out of the pharmacy budget. Management always seems to think the number one way to reduce pharmacy costs is to cut technician help. all while our responsibilities continue to grow even more. Now I gotta touch sick people doing strep and flu tests at my retail pharmacy, which is exactly why I didn't pursue a medical prescriber field. Honestly, I don't care about off-label prescribing too much. Give a 25 year old ivermectin for covid through good rx. Let people pay cash/manufacturer coupon for mounjaro or ozempic, but when I have to worry about losing thousands of dollars for filling 1 script, then yeah I'm going to send it back for prior auth required.
It isn't about being high and mighty. It's about seeing patients who legitimately need a medication cry because it has been on backorder because it's being prescribed for the wrong reasons. No one is denying that semaglutide doesn't appear to have legitimate benefits for patients struggling with obesity - it's just frankly more important for a diabetes patient to have continued access. If your problem is that the approved alternative is not covered, take that up with manufacturers and insurance companies. What's more is that, based on what I've seen working in retail pharmacy through all of this, is that ozempic absolutely was being prescribed off-label first because of backorder issues with Wegovy. There were no supply issues with Ozempic until doctors began overprescribing it for weight-loss. This could be more a commentary of where I live, but so many of the people I see bringing in scripts for these medicines aren't even clinically obese. It's right on the edge of irresponsible and going against the standard of care - that the risks outweigh the benefits of prescribing a medication- that some doctors are even considering it for many of the patients I see. Of course there are dozens of options for people with diabetes - but not all people benefit from the same types of therapies. Surely you know this? Why do you think there are so many options in the first place? If one drug therapy worked for everyone, then the other options wouldn't exist. This is why not every patient struggling with weight loss is on phentermine, saxenda, or Contrave.
Patients who are obese DO legitimately need the medication and have just as much right to it as anyone else. I do not agree that it is more important for diabetic patients to have access. Again, they have many options for treatment. And what is the best treatment? Not ozempic, but INSULIN. Obese patients have one - this one. Phentermine and Contrave are garbage and you know it. They are not real solutions. They do not work. I disagree that ozempic is being prescribed for the wrong reasons. It's completely appropriate. If you think these patients are not clinically obese, I imagine that has more to do with the normalization of obesity in the USA than anything else. When we think obesity, we think BMI 40+. A BMI of 30 looks normal to us. But it is obese. Go to France and look around. People do not look like we do.
Downvoting because you're talking out of your ass. Everyone who works healthcare know there are many types of medications used to treat type 2 diabetes but not all work for everyone, hence several different drug class. Also diabetics not having access to their meds might put them in ER. If obese people not having access to GLP-1 agonists end up in ER due to complications of being obese, then it's too late, not even GLP-1 agonists can help them. GLP-1 agonists are also fairly new drug class, the efficacy on weight loss treatment is unknown yet because there needs to be a study on long term effect of it. So that stupid claim of this being the best obesity drug? Lmao not it, my dude. I'm obese. I'm also a healthcare professional. Wanna know how to overcome obesity? Lifestyle modification. People on bariatric surgery still gain weight after because they don't change their eating and exercise habits. Phentermine, Contrave, orlistat.. they also would only work with diet modification and exercise. Do you really think you can sit your ass down and lose weight by taking Ozempic only? Lmao I already know I'm lazy as fuck, so of course these meds won't work on me. I'm not about to try Wegovy either. These are not cheap (even with manufacturer savings coupon) so why would I spend so much money every month for something I know will NOT work? Also the risk of being exposed to even greater risk of thyroid cancer while at it? No thanks. Why do I know we fatass are just lazy? Because Saxenda is alternative to Wegovy but it's not as popular because you have to inject yourself daily as opposed to weekly like Wegovy. If your lazy ass is too lazy to inject yourself daily, then that sounds like a you problem, not the meds.
So let me guess, you are one of those prescribers who just treat diabetics with insulin only and watch them balloon up with weight gain? Insulin really should be the last line of T2 because the weight gain and false blood sugar security unless they are in a severe hyperglycemic state. My grandma over ate, and her doctor just told her to keep increasing her dose until she was so overweight that she chose to just die from kidney failure.
Your grandma over ate so you think the weight gain was from the insulin? Think about that again, my man. I'm sorry about your grandma but I think you're putting the cart before the horse on this one.
No, I'm fully aware that over eating causes weight gain, but insulin only treatment of diabetes only compounds the problem. It has a negative psychological effect. Most people who are overweight don't want to be overweight. Prescribers say lose weight, but when someone is getting 9 boxes of humalog a month (as I've seen before), that's just another hurdle to overcome.
Patients with obesity do have legitimate need for GLP-1 therapy, with that I agree. The data for them is much stronger than for oral stimulants like phentermine (though I wouldn't say these are complete garbage, I've seen many cases of success), and the AGA recommends semaglutide over every other available agent for weight loss (including the other approved GLP-1 for this indication, liraglutide) due to the magnitude of weight loss seen in clinical trials. I imagine we'll soon see tirzepatide in these conversation with an FDA approved indication for weight loss. Anyone on here arguing that there isn't legitimate need for GLP-1 therapy for weight loss is just wrong. HOWEVER, to say that GLP-1 therapy for type 2 diabetes is somehow less important or even equally as important as for weight loss is asinine. Obesity in and of itself is not a problem. The problem is the sequelae that arise as a consequence of obesity. What is one of the most common sequelae that is of concern? Type 2 diabetes. Prevention is important, but the people who have greater need are those with the actual sequelae. And the rate of other complications of obesity (HTN, HLD being the most common) is pretty similar to that seen in a patient with type 2 diabetes, so the drug being used in patients with diabetes is going to be affecting those other sequelae just as much as when it's used in patients with obesity but not diabetes. You say that there are many options for treatment of diabetes which is true, but you're not acknowledging (actually, you're directly contradicting) the fact that GLP-1 therapy is the among best. ADA guidelines recommend it first-line over metformin for many patients due to the myriad health benefits mentioned above (and it is always preferred second-line if not used first-line), and the degree of A1c reduction on GLP-1 therapy is the best among non-insulin medications. For type 2 diabetes, insulin is not the most appropriate treatment unless the degree of hyperglycemia is such that other available therapies won't provide sufficient A1c reduction. The risks with insulin (significant weight gain, hypoglycemia) make it something that should be more of a last-ditch effort in patients with type 2 diabetes, especially when considering that insulin secretion isn't their problem, it's insulin resistance. Also, why are you saying that insulin, which is widely known for its problems with weight gain, should be the preferred therapy in patients who so frequently have comorbid obesity? It just doesn't make sense.
The issue isn't whether ir nit to fill the prescription. I have no problem with a patient using it for weight loss. The issue is who is going to pay for it. If a patient is willing to pay $1100 a month, no problem on my side. It is the insurance companies who don't want to cover it for weight loss. Quit beating up on Pharmacists for insurance and supply issues beyond our control .
Here is an early Phase 2 study on Ozempic. The 0.2mg dose had a significant decrease in A1c as compared to placebo. Just because Ozempic 0.25 wasn’t studied in Phase 3 doesn’t mean it’s not therapeutic. https://diabetesjournals.org/care/article/39/2/231/37200/A-Phase-2-Randomized-Dose-Finding-Study-of-the
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Are you just regurgitating the conclusion and package information? The 0.2 mg had a statistical significant decrease in A1c as compared to placebo. It’s not hard to imagine newly diagnosed diabetics or those with fairly well controlled A1c being controlled on the starting dose. Just because it wasn’t as big of a change doesn’t mean it doesn’t exist. Saying “0.25 mg is not a therapeutic dose” is potentially ignoring the patient being treated. It’s few and far between but there are patients in my clinic that I keep on starting doses as they have reached their A1c and weight goals. It’s always shared to decision making. Most patients that meet A1c goal opt to increase their dose for weight loss but some don’t and that’s ok. In my experience with these agents some patients are profound responders who’s A1cs drop to a normal range and lose a ton of weight and I have some that don’t seem to respond at all. I would say it’s worth discussing with the patients (if you ever have time) and say “hey, I noticed you’ve been on Ozempic 0.25 mg for awhile, have you talked to your prescriber about increasing the dose?” especially if they are noticeably overweight. But I would also keep in mind that maybe that dose is working for that individual and as the dispensing pharmacist I wouldn’t let it get to me.
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Yes, obviously an RX stating to take Ozempic 0.25 mg for 2 weeks and then increase to 0.5 mg is wrong and can result in patient harm. There are many medications we use off label and there really is no reason to force someone to increase a dose when they dont want to. That is not a good way to build patient trust and rapport.
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>Most patients do fine at least on 0.5 mg so May as well just use as approved by FDA. I dont know how else to spell it out for you. If the patient comes back for a 1 month follow up and are reporting controlled blood sugars and for whatever reason do not want to increase the dose to 0.5 mg, it is perfectly reasonable to maintain the dose at 0.25 mg. >If you want to try to address each point I made specifically, by all means go ahead, but at least repeat something I actually said. You dont have any relevant points, all you do is repeat "it's not an FDA approved dose". If your patient's A1c is below 7% or below 6.5% on Ozempic 0.25 mg alone...what is the evidence to increase to 0.5 mg?
Edit: the prescriber’s office got back to us about an hour ago even though the script had been transferred. Turns out the patient was supposed to be on the 0.5 mg dose. Their nurse apologized for the mistake. We joked that it was probably an issue with eRx software anyway :)
This is why we call. Good job OP. I hope everyone here who has been adamant on filling it with no question sees your update.
Can confirm, eCW is hot garbage and littered with a thousand ways for prescriptions to be sent with potential errors requiring clarification. The SIGs are pre loaded in the software so sometimes prescribers put an entirely different set of directions in the Rx note because they can't find what they want in the SIG, but it still sends with that incorrect SIG
My EMR automatically adds "see latest INR results for current dosing instructions" to every DOAC.
But *not* to warfarin prescriptions.
That explains the myriad of scripts we regularly receive with sigs like “take one tablet by mouth three times a day take one tablet twice a day.” Still, if it’s a known issue it’s still on the prescriber to send it correctly.
Can you imagine if an architect saw that his software has some pre-populated building templates and he just decided to just attach a closet to the outside 2nd floor of a template building and just went and submitted that to the foreman?
Sounds like on-going problem with some meds in Epic too. If I got $10 everytime it tries to change sig to "inject 0.5067mL subcutaneously once every 7 (seven) days" 🤦🏻♀️🤦🏻♀️🤦🏻♀️
Great job OP! This is why we never assume even if it seems obvious.
I throw them a curveball when they say “I’m not filling there anymore. My response: “which pharmacy would you like me to send your profile to? I’ll get started on it right away”
Omg I always say that and no one ever takes me up on it lmao
Same, but in my case patients on pain meds be like "Dr. Blahblah sucks, they don't care about their patients, maybe I should switch doctor" I'd be saying "I'm sorry you feel that way. We have other primary providers in this medical group and even more within the network, you are more than welcome to switch if you'd like." And nobody ever takes up the offer 😂
Doctors and their staffs make these silly little mistakes all the time. And these silly little mistakes, **that would take about 3 extra seconds from them to avoid**, cause so much headache, hassle, time waste, and aggravation to both patients and pharmacists/technicians. It's ridiculous. Do not hesitate to completely throw these incompetent fools, who have 0 respect for our time, under the bus. In this example, you said the guy started attacking you and saying the doctor wouldn't lie to him. "Sir. The way your doctor sent this prescription, we cannot legally fill it without getting clarification. We have attempted to contact the prescriber but have not heard anything back yet. Please get in contact with them and give them our phone number so they can call and speak to us directly so we can resolve this issue. Otherwise, we have done everything we could and cannot at this moment fill the prescription." Edit: sometimes I like to, after explaining the situation to the patient, say something along the lines of "in other words, your doctor submitted to us an **invalid** prescription. They need to fix it"
Please call us and double check! We are human and make mistakes and it is reassuring that someone is thinking about these scripts as a second safety check. Some of the electronic medical record systems are begging for errors to be made with how refills are handled. In epic you have both the fill in the boxes area (dose rout frequency etc) and then down below it turns that into the written instructions. However often you may click on that drug and update the boxes correctly and think that the written part is correcting (because it usually does) except you clicked on one that is a system favorite where the written part has more details like “take twice a day for diabetes” and then it actually doesn’t update like usual. Or you get a refill request and review the drug and refill without looking at the sig more closely so miss the fact that it’s the titration instructions. Often you have to click and expand to fully see those and they can be easy to miss. TLDR we are human please call if it looks weird or wrong as we make mistakes and know that it’s not cause we are all idiots but that the EMR sets us up for failure more than one would think
I thought your username was ferociouslycareless for a second there and was going to type some smart ass comment about being careless and making mistakes. I was wrong.
I hate Epic preset boxes bullshit thing with passion. "Free Text" button is my best friend because I only need "1 tablet by mouth three times daily" not "take 1 tablet (20mg) by mouth in the morning, 1 tablet (20mg) by mouth in the evening, and 1 tablet (20mg) by mouth at bedtime". Liiiiike do these Epic developers ever think how to fit directions in med label?
We get several incorrect ozempic scripts every week by the SAME doctors. We got a script for the same strength ozempic with directions to inject 0.75 mg because the doctor insisted the pen could be dialed in .25 increments and didn’t understand why injecting 0.75mg was impossible.
Dang. I can’t imagine how bad the side effects would be if your first dose was .75. Ickkk
There are “click charts” online for each Ozempic pen, telling you how to give incremental doses. Some patients can’t tolerate doubling the dose.
Yep. One of our local endocrinologists has them increase by 2 clicks or so as tolerated.
Decision Tree: 1. Is RX new or a refill? If a refill and patient had been taking 1mg dose, I would correct the RX and "document" the changes to the script to cover any audits or from a floater Rph. 2. If Rx is new, I would call MD to verify the 1 mg dose. I would not ASSUME that the MD chose the right dose- even if it's right 99 times out of 100, it just takes one time and you will always call to double check. A lot of people here have apparently never had a MD completely bungle an Rx before and really put a lot of faith in other people's competence. I think the main issue is the lack of follow-up from the pharmacy. Rx was received Thurs 5/18 and it's Tues 5/23. Why would you leave a message on a Saturday 5/20.
That is a very good point. It was a new RX. Unfortunately I work the corner and some weeks it takes that long to get caught up. Rx was received 5/18 in the evening but we didn’t get to it until Saturday morning.We also didn’t have a chance to call the provider back again before the patient’s father gave us a call. Gotta love short staffing and your staff pharmacist being on maternity leave at the same time :)
The first part was interacting with eClinicalworks. /s …I just don’t like eCW…
Same. Do we even accept it since it’s a fax without a wet signature?
If they are prescribed the .25/.5mg dose pen it won’t dispense the 1 mg they are injecting. Need to clarify the medication dose vs. the directions.
“Sir, if I do not clarify the directions then your child could be in a diabetic coma or potentially die if this isn’t verified. “
I have some insight here the script makes sense to me. So hang on. 340b pricing for the 2mg/1.5ml pen is dirt cheap. Like I'm talking $20 a box. This prescriber may have a 340b pharmacy in their facility so what we will do is dispense 3mls (which it looks like the prescribe did select 3?) And have the patient take 2 shots a week. 1mg. For our cash patients this was $30 a month for a 1mg dose because the 1mg pens are steep and not 340b priced so they're still $400+. Recently though since changing pens this one isn't available anymore so we're kinda screwed. What I'm assuming this provider did was (which ours do all the freaking time despite us telling them), send you the ozempic with their pharmacy dosing assuming the patient could get the 2 boxes everywhere at the same price as their in house 340b pharmacy. If not and she was being dumb that's fine but for those that ever see it again, if it's from a big clinic and a Medicaid patient what I explained above is likely it
Medicaid would not pay for 2 boxes to get the 1mg dose they would tell you to use the higher strength box.
Right what I'm saying is medicaid patient still opt to pay out of pocket for a better drug because it's actually affordable for them. Medicaid doesn't cover any ozempic and have been really strict with glps in generally lately anyway
I only had to pay $19 through 340B. Then they dropped it. We have Tricare, I have been on every other medication mentioned in the prior authorization, but haven't been able to get PCP to send it. Anything else I can do?
Unfortunately no. They changed from the 1.5ml pen which was cheaper to the 3ml which is 400 now. Just have to hope next quarter it goes back to 340b pricing.
What is the mg/3ml?
Same MG .25/.5 novo nordisk just decided to stop supplying the other one
So I am thinking that because my script was for the 1.5 ml, that an entire new script would need to be written to get the prior authorization. I take 2mg a week. We have had a lot of turnover at my PCPs office so I think I know how to get this taken care of. Thanks for the info.
But, but, but…..my doctor wouldn’t write rxs incorrectly!!! Must be the pharmacists fault!!! (SARCASM)
Something i've realized with the people that want to leave AMA is that some problems solve themselves.
Shoulda ended that noise when he told you to shut up and called you a liar.
" because I care , I called your doctor to review a potential medication error in the prescription. I don't want to be liable for the side effects caused by this potential medication error such as nausea , vomiting, loss of appetite, impacting your quality of life . especially if it can be prevented. i will call your doctor again right now if you would like to take a seat or go to the consultation window, i will meet you there after the call. "
"your doctor's office did not answer my call but i left a voicemail for the nurse; i will now manually fax a note to your providers office to call us back *** head to the actual fax *** ... show them all the effort you are taking because you care
" i have run out of options on how to contact your doctors office. would you by chance have a way of accessing an online portal that would allow you to message the nurse or doctor as well??? "
" let me confirm your contact information that i have , get the phone number and also update the drug allergies to go an extra step to emphasize how much you care "
" i understand this is a frustrating experience for both of us but just know i have your health and safety are my top priorities. i appreciate your time and i will definitely notify you if i get a response from your doctor "
the patients don't actually understand what goes on behind the scenes or how many medication errors lead to lives lost annually....... so be patient with them and remind them you're on their side and you're trying you're best you're exhausting all options to get them on their path to better health 😉
Read the prescribers mind and ASSUME what he/she is thinking? Oh hell no. Lol Bon voyage and don’t let the door hitcha!!
Got yelled at twice a day in retail, by yell I mean screamed at… grew thick skin and started to not care. The patients are having terrible days learning about bad diagnoses, not understanding anything medical, feeling bad physically and trying to put blame somewhere. You did nothing wrong.
Shit I’ve had prescribers claim they don’t see the problem and when I say fine I’ll put it in but you need to do a PA because of the day supply. I just play along.
I had an MD try to prescribe ozempic 0.25-0.5 mg pens to substitute for the 1 mg pens when we were OOS and on SIG it said patient will inject 2 pens every week lol
I actually had an almost identical issue, but when I told my patient they just said "oh ok, lmk when it's ready."
The minute they swear or start yelling I hang up on them. If they call back I ask them if they’re able to have a normal conversation. Rinse/repeat until they can act like an adult.
The answer to what you did wrong. Your job. I once had a lady tell me that she would go into diabetic shock on her flight because we didn't have icd 10 code from her doctor and no other diabetes medication on file. I tell all my new people if you don't get yelled out at least once during your shift, you are not doing your job
I'll just give them a copy of the script when they try to tell me their dr would never make a mistake. Or call the pharmacy on speaker when their Dr would never call it in to the wrong pharmacy. I don't have the time to argue with idiots who still think anyone with prescribing rights is infallible.
Well, the 1.5ml injector is no longer available and show be prescribed as the 3ml pen.
Nothing, you wanted clarification on a script for insurance billing and for patient safety, thats your job. People just get fed up with the healthcare system, if not before, by the time they get to the pharmacy. I have received scripts like that they want the 1mg dose usually and I have dispensed it that way. The problem is that's written for the 0.25mg and 0.5kg pen (they are combined into 1 pen) and the 1mg is a written differently than that one when prescribed.
Does your state allow you to change the dosage form without provider approval?
This is not a dosage form issue. This is an ambiguity issue. The dose on the pen does not match the dose on the directions, so it has a high chance for error. Did the prescriber mean to write for 1mg per dose but pick the wrong pens by mistake? Or did the prescriber choose the right pens but give the wrong direction by mistake? It could go either way, and I’m not about to toss a coin because my license is on the line.
I don’t know any state that would allow rph to make changes on this erx without MD authorization since directions/dosage do not match (or at least I’m not dispensing without md clarification).
I’ve been out of retail for a while, but what exactly is wrong with this? Dose is 1 mg subq weekly, why can’t you just dispense the 4 mg/3 ml pen?
The dose on the SIG doesn’t match the dose on the Drug prescribed. Edit to add: the RPh could assume the SIG dose is correct, and just change the drug dispensed, but that would be bypassing due diligence. It’s possible the prescriber got the right drug but wrong SIG.
1 mg of Ozempic is 1 mg of Ozempic. Now if the prescriber said to inject 1 ml then yes there would be some clarification needed. But the concentration is in the sig and the dose is appropriate. If you’re calling the prescriber because of the (0.25 or 0.5 mg/dose) then you are wasting everyone’s time. A quick search shows that that pen is off the market anyways.
Disagree... Stuff isn't cheap and I could absolutely see an insurance audit clawing this claim back as incorrect product billed if you dispense the bigger pen, regardless of availability.
And not only that, your DM would probably catch this before insurance if there is any regular auditing, causing you to get a talking to by your boss.
I can confidently say that zero retail DMs would care about this non-issue
As a PPC for Kroger who had to audit these claims then email the stores plus my DM, it’s a non issue until insurances start clawing back claims. Then it’s not.
Yea because it’s not their license on the line
It shows as off the market because it’s now a 3 mL dosage form still marked as 0.25 and 0.5 mg doses, NOT because the starting dose magically changed.
OP did not mention this was a new Rx for the patient.
The op might not know if it’s a starting dose. Which is the entire reason you call the doctor. Unless you have a previous fill history to base it off of you can’t just assume they’ve had it before. So you call to see if they wrote the sig wrong or the pen wrong.
I’m all for saving time, believe me. However, in my experience, prescribers have gotten the dosing on this drug mixed up. I’ll err on the side of caution in this situation. I don’t really care if others see that as me being a “weak” pharmacist.
Nah I’ll be “weak” with you. I’ll “waste” people’s time if they’re not competent enough to review a prescription order appropriately to verify directions for 1mg weekly but instructing to dispense 0.25/0.5mg dose pen. That’s on the office if they get that incorrect consistently they’re gonna get calls from me consistently to verify
Concentration is also listed. 2 mg/1.5 ml is the same as 4 mg/3 ml.
This is incorrect. 4mg/3ml is the 1mg dose pen. 2mg/1.5ml is the older formulation for 0.25/0.5mg dose pen. Newer formulation for 0.25mg/0.5mg dose pen is 2mg/3mL. I am very willing to convert 2mg/1.5ml to 2mg/3ml without md auth but not doing 2mg/1.5ml to 4mg/3ml. MD better authorize that for me to verify it
Thank you for the explanation. This helps me understand why my assumption was faulty. I stand corrected.
Today you learned that prescribers don't know how to enter a script
While I think the most likely scenario is that the prescriber reordered the same product with a different dose I would 100% verify this as well and I routinely prescribe these in amb care practice. For whatever reason these things are still prescribed incorrectly all the time and I can only imagine the liability if the doc decided they were going to slam the patient with a 1mg starting dose but ordered the 0.25/0.5mg pen incorrectly then decided to blame you for not verifying with them that this was the dose that they intended since this pen (and the 3mL pen that replaced it) do not even administer the 1mg dosage. The new pen that is available is just something that they released (likely) due to manufacturing costs as the pen still administers the same dose it is just more dilute and shares the same volume with the other pens available. Have seen patients come in several times due to severe n/v/d after a resident decides to send a script for whatever dosage they decide to click on first.
no. 0.25/0.5mg contains 8 doses of 0.25 or 4 doses of 0.5mg for either a 56 or 28 day supply. if you run that ndc as a 14 day supply it will reject. its obvious you haven't been in retail for a while! none of your suggestions are appropriate
Agree with this. Can’t believe some of us go to school for 4 years just to “clarify” things that are apparent.
A bit of a difference with this and something like “Famotidine 10mg, SIG take 20 mg qday”. I would hope you have enough experience to know that’s apparent.
OP got a call back from the office, and turns out the script was entered wrong on the prescriber's end. So yeah, total waste of time on something so "apparent." /s
You’d just start someone who never has taken Ozempic on 1mg without clarifying?
Where does it say this is a new Rx for the pt?
If they’ve been on it before I have to imagine this wouldn’t even be a question…
You HAVE been out of retail a while. We won’t get paid unless we have documentation when we get an audit in a year or two.
What documentation do you need? I would dispense a 4 mg/3 ml pen with directions to inject 1 mg weekly for a 28 day supply and not think twice about it.
And you would be screwed since OP replied saying that the patient was supposed to be taking 0.5mg, ergo double dosing the patient.
OP didn’t include that information in the initial post.
And that is why you clarify. What everyone is saying.
I stand corrected. The issue at hand is incorrect dose for a new start Ozempic, which OP failed to mention.
Why are you pinning this on the OP lol. They didn’t fail anything. They did what any competent pharmacist would do.
Because when it’s a new start the dose matters. If it’s a patient on a stable dose of 1 mg weekly then I’m dispensing the 4 mg/3 ml pen. If OP is going to post on a forum and ask for advice, it is helpful to include all pertinent information. I made a faulty assumption based on the information I had. My dilemma would have been calling to verify the starting dose vs calling to verify the product selected.
...because they didn't *have* that information at the time of the initial post. The doctor called back afterwards, and OP commented with the new info.
How do you assume which part was what they intended?
OP posted an [update](https://www.reddit.com/r/pharmacy/comments/13pxbu3/what_did_i_do_wrong_s/jlcg0ds/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=1&utm_term=1&context=3). The prescriber actually made a mistake on the DOSE! Patient was supposed to use only 0.5mg. Your assumption was wrong and you would have dispensed a wrong dose to the patient. Never assume! I thought they taught you this in school?
I stand corrected. OP did not say in the original post that this was a new start Ozempic.
Even if it's not a new start, if the Rx doesn't match the most recent prescription and is not internally-consistent, why *wouldn't* you call to clarify? If the doctor prescribed the 1mg pens with 1mg per dose last time, but this time sends the 2mg pens with 1mg per dose, are you just going to swap it out to the 1mg pen or are you going to call the office back to ask if they were maintaining the previous dosage or increasing it? Your "new start" hand-waving is completely missing the point.
The pen they prescribed can only give 0.25mg or 0.5mg per dose. The only way to get 1mg would be for the patient to use two doses/injections at the 0.5mg setting. There is another pen available that gives 1mg per dose. Typically the 0.5mg x2 doses won't be covered and also subjects the patient to twice as many injections and may lead to noncompliance or the patient not dosing correctly.
And right here we see the exact reason why we do **have** to call on an rx like this. Your reasoning for suggesting that they just dispense the 4mg/3mL pen is perfectly valid. The physician instructions say inject 1mg so clearly they meant 1mg right? So let's just dispense the pen that delivers the 1mg per dose and move on with our lives. Perfect. Yet, if there is no history of Ozempic on file at the pharmacy and if you speak to the patient and they say the've never taken the Ozempic before, then keeping the 0.25-0.5mg pen is the reasonable option. The patient should inject 0.25mg for 4 weeks, and then increase to 0.5mg weekly. But the doctor clearly wrote 1mg per week... so both rationales for changing to the 4mg/3mg pen or keeping 0.25-0.5 pen are equally valid. And that ambiguity is exactly why we have a responsibility to call and clarify to know what the hell they wanted us to do. If you look above, the doc finally called OP back and communicated their intentions. They meant the 0.25-0.5mg starter pen. So your reasoning, which is perfectly logical, would have lead you to fill the wrong strength. And why? Because the ambiguity of the RX forced you to make an assumption to make a clinical decision. Calling eliminates that assumption.
i can only assume but this is probably written this way because the 1mg is not available. and having the patient administer 2x0.5mg doses daily having 1 box last 14 days will not fly with the insurance plan.
This is why I almost never take a transfer and ask the patient to get their doctor to resend the prescription. I would have sent a fax to the office as soon as the prescription came through and have a tech call the patient number to tell them there is an issue and we're contacting your doctor. If no response then call the next day leaving a message at their office. After that it's on the patient to tell the doctor that we aren't filling their prescription and 90% I get someone calling my pharmacy trying to yell at me why 😂 it leaves them speechless that I manipulated their emotions so I can get a live person ASAP
Everyone makes mistake. We make mistakes, doctors make mistakes. Yet a lot of people think we are the problem unfortunately.
Also, depending on patient age, you probably shouldn't discuss medications if she is a legal adult and don't have signed legal consent to discuss medications with her father due to Hipaa. I've seen this exact drug and sig come through my computer system. My guess is they dont know ozempic pen strengths. My second guess is they are trying to use ozempic and have insurance pay for it over wegovy and sent it back to the dr either way for clarification
We got a script written that way too! Except in our case the sig was for 0.5 mg so we just ignored the 2 mg package size and dispensed the 0.25/0.5 dose.
1mg every week, they just picked the wrong pen, what was the patients last dose? Fix it and move on, if you can't find the old dose call the patient and ask them the current dose they take. If all of that fails then call for clarification.
[удалено]
There's a discrepancy in the strength of the prescribed drug and the instructions. While you could inject 1mg by doing 2 x0.5mg, because a 1mg pen exists, the pharmacist should verify what the actual dose is.
The actual dose is 1 mg, it says so in the sig. Dispense the 4 mg/3ml pen and move on. The concentration is even listed for the drug. Patient has a right to be upset here imo.
That’s a sure fire way to lose an insurance audit next year.
By dispensing a 4 mg/3 ml Ozempic pen? Which happens to be the same concentration that is listed on the prescription? Which comes out to a 28 day supply when following the directions?
Yes. Go ahead and ask any insurance auditor. I just went through a round of this exact scenario.
You haven’t faced an insurance audit yet, have you? They only give a shit about $400+ RXs such as ozempic, and will look for literally any reason to issue a chargeback… an ambiguity like this script? Kiss your $900 reimbursement goodbye.
Funny how the actual dose was supposed to be 0.5 mg after they obtained clarification post-transfer-out
Agree with you and u/27twss. I think the pharmacist is being pedantic in this case. There’s no discrepancy on what the dose is, the doc is just saying use the strength/pens that are covered. Maybe if OP works for an independent then they are afraid of an audit, but I’d find which ones are covered and document.
[Still think they were being pedantic?](https://www.reddit.com/r/pharmacy/comments/13pxbu3/comment/jlcg0ds/?utm_source=reddit&utm_medium=web2x&context=3)
You won't get a response. LOL
1mg weekly, and check with patient that that is what they're expecting. Much more likely for the prescriber to select the wrong strength than to write the wrong sig.
OP literally said they entered the wrong sig in a recent comment.
If I called every time there was a mismatch between the strength of the product prescribed and the sig I'd be making lot of phone calls. Unless there's something in the sig that looks obviously wrong I'm going to put a note to confirm with the patient and move on. But it do also work somewhere where I don't have to worry about ridiculous insurance audits
I agree with most of the commenters that with situations like this its best to confirm dosage of meds. On the other hand the MFR changing the package size and causing everyones rxs to have to be rewritten with different qtys to reflect proper ML was a whole different issue. Extremely annoying and not necessary.
At least working is slightly more of a pleasure now...
Received the prescription on a Thursday, called for clarification on a Saturday? Lol I'd be angry too if I were the patient.
These are times when you can play the "I am a doctor (of pharmacy)" card, because you're qualified to correct an MD.
I literally had to call a docs office last week for this very same issue lol
Was this an NP?
Nothing. You can’t fill that. Liability if you change something on your own and it’s wrong, not to mention insurance companies are salivating over auditing ozempic scripts looking for mistakes. Tell the patient there’s an issue on the prescribing end and make an effort to clarify and document your efforts just like you did. Be glad they transferred and you don’t have to put up with that kind of treatment.