Medication refills/Is this ethical?

[Veronica97]

I take care of filling my elderly in-laws’ medication holders every week and also take care of ordering refills for them because they both have problems with memory/cognition. My MIL’s doctor has just reduced her heart medication from 1/2 pill twice a day to 1/2 pill once a day. She is going to be out of her medication in a few weeks, so I need to get a refill for her, and she has at least a couple of refills left. However, the old label says “Take 1/2 pill twice a day” and so it has 90 tablets for 90 days. She gets her medication from a mail-order pharmacy that dispenses a 90 day prescription for a certain price. Now if I refill this prescription, she will be getting 90 tablets, but it will last her 180 days instead of 90 since she will only be taking it once a day now. (I hope I’m making sense). To me that sounds almost like we’d be cheating the pharmacy–getting twice the medication for the same price. Is it okay to get the refill for the 90 tablets or should I ask the doctor to write a new prescription with the new once-a-day directions?

 

[WKW_69]

If the prescription has changed you must inform the pharmacy. This is not only ethical but a legal requirement. Have the pharmacy contact your doctor.

 

[1ke]

You aren’t cheating the pharmacy out of anything. They are selling 90 pills, and you are paying for 90 pills.

Why don’t you have the doctor issue a new prescription if it concerns you?

 

[NeedsMercy]

It’s not cheating. Your MIL is probably paying a very dear price for such coverage. Use it.

 

[sscott]

How are you cheating the pharmacy? What used to be one prescription for 90 days will now last 180. You are paying the same amount for each pill. When these refills run out the doctor will issue a new prescription for 90 pills for 90 and you will go back to ordering every three months.

 

[bitterhope]

No, drs change the directions often and sometimes even write the script in a way that the patient is given more medication so that it is more affordable to the patient. Follow the drs recommended dosage and it is fine. I am a pharmacy tech (but currently a housewife–only work when absolutely necessary). We see this happen all the time.

 

[JSSD]

You aren’t cheating the pharmacy out of anything.

You are correct, it would be cheating the 3rd party payor, not the pharmacy.

She gets her medication from a mail-order pharmacy that dispenses a 90 day prescription for a certain price. Now if I refill this prescription, she will be getting 90 tablets, but it will last her 180 days instead of 90 since she will only be taking it once a day now. (I hope I’m making sense).

If the benefit is written as days rather than pills, yeah, technically you are cheating. Fraud is a really strong word, that I probably wouldn’t use, but not necessarily inaccurate here, and I can’t think of a lesser one off the top of my head. You’re likely saving yourself (or your MIL) half the copays, +/- deductibles plan, etc.

If the prescription has changed you must inform the pharmacy. This is not only ethical but a legal requirement. Have the pharmacy contact your doctor.

Having said what I did above, here is a law that’ll never be enforced. Physicians & patients do this all the time. Does it ultimately get baked into the AWP and specific contract pricing? Sometimes they do it when the care delivery and payor are one and the same. So, are they cheating themselves?

A better reason to tell is for safety, etc. Let your pharmacist know, this medication change may have downstream effects for other medications. Chances are pretty good it doesn’t, but some meds do.

I also agree with 1ke - you should probably tell because it is concerning to you.

No, drs change the directions often and sometimes even write the script in a way that the patient is given more medication so that it is more affordable to the patient. Follow the drs recommended dosage and it is fine. I am a pharmacy tech (but currently a housewife–only work when absolutely necessary). We see this happen all the time.

Yeah. It doesn’t make it right (moral), IMHO, but it happens 11ty billion times / day. I would never call someone out on it, but if you asked me for my opinion in real life, you’d get what I typed above.

(as a former pharmacist)

 

[JSSD]

You are correct, it would be cheating the 3rd party payor, not the pharmacy.

If the benefit is written as days rather than pills, yeah, technically you are cheating. Fraud is a really strong word, that I probably wouldn’t use, but not necessarily inaccurate here, and I can’t think of a lesser one off the top of my head. You’re likely saving yourself (or your MIL) half the copays, +/- deductibles plan,

And I should clarify to soften these even more by saying this is only true if you are filling more than you need/ordered/should.

It sounds like that isn’t the case at all, but it happens all the time.

 

[Veronica97]

You are correct, it would be cheating the 3rd party payor, not the pharmacy.

If the benefit is written as days rather than pills, yeah, technically you are cheating. Fraud is a really strong word, that I probably wouldn’t use, but not necessarily inaccurate here, and I can’t think of a lesser one off the top of my head. You’re likely saving yourself (or your MIL) half the copays, +/- deductibles plan, etc.

(as a former pharmacist)

That’s kind of how I feel about it. I just called the doctor’s office and left a message that MIL would be out of her medication in 3 weeks and she would need a prescription called into the mail order pharmacy. I left it at that…hopefully the doctor’s office will call it in with the new directions.

 

[JSSD]

That’s kind of how I feel about it. I just called the doctor’s office and left a message that MIL would be out of her medication in 3 weeks and she would need a prescription called into the mail order pharmacy. I left it at that…hopefully the doctor’s office will call it in with the new directions.

That is a fair expectation; likewise, you can have the mail order pharmacy call the MD office to clarify the script. “I’m told it is changing, can we get a new prescription on file?” etc.

 

[pnewton]

I guess one must do what one’s thinks best, but darned if I can think of an ethical violation. I can think of no legal violation. Nothing is stolen. It seems this is more of a prudent choice than a moral one.

 

[JSSD]

I guess one must do what one’s thinks best, but darned if I can think of an ethical violation. I can think of no legal violation. Nothing is stolen. It seems this is more of a prudent choice than a moral one.

Think of it this way:
You have ‘brainitis’ and for it you need a prescription for ‘supercillin,’ which your physician provides you. You have entered willingly into a contract for prescription (and other) coverage with JSSD-insuranceCO. Supercillin is on my formulary and SupercillinMFG, the pharmacy, and InsuranceCO all have contractual arrangements as to price based on volumes, preferences, etc.

Your contract says you may get a 90 day supply, and I’ll pay for the bulk of the medication and you are maybe responsible for the co-pay. SupercillinMFG may have priced that medication equally across doses or increasing price with increasing dose. Both happen. But they expect you’ll use the medication as intended by dose (disregard off-label for this).

For brainitis, I expect to pay 4 times / year to treat your condition, and SupercillinMFG expects to be paid 4 times / year. In this case, we’ll be going around only twice. Granted, I’m paying less to the pharmacy, so are you, and the pharmacy is buying (very incrementally) less for you, but SupercillinMFG wants theirs. Use the smaller dosed tablet, or enter the prescription correctly. Perhaps I don’t want to give you a half year supply, in case the medication doesn’t work and you need to switch. Now we have tremendous waste and we’ve all paid for it. Safety issues can also arise from this, although that being a separate issue.

It certainly isn’t the most compelling argument, that is for sure - but therein lies you potential breakdown of the contract / ethics / prudence. Multiply it out across a drug that may cost $10,000, $20,000, $100,000 / year. Of course in those cases, there are other mechanisms to prevent this. Do with the info what you will, of course.

 

[pnewton]

Think of it this way:
.

I thought of it that way. I still do not agree. The only company you contract with is the insurance company. If you are paying less, then they are too. The only person making less is the manufacturer maybe the store. There is no obligation to support any company by buying in quantities that cost more.

 

[JSSD]

I thought of it that way. I still do not agree. The only company you contract with is the insurance company. If you are paying less, then they are too. The only person making less is the manufacturer maybe the store. There is no obligation to support any company by buying in quantities that cost more.

OK, but would you agree you aren’t upholding your end of the contract? You may both be paying less, but the circumstances are not what you agreed to. You agreed to a 90 day supply, but without telling them, you have come upon a 180 day supply.

Here is where this becomes problematic and the real reasons benefits work as they do: Let’s say Veronica97’s MIL’s sister also has brainitis, as it runs in the family. Likewise, they probably take the same dose, family members often being of similar pharmacokinetic profiles. Veronica could very easily refill her 180 day supply every 90 days because she never corrected the profile at the pharmacy or with the insurnace. In effect, she could supply the hypothetical sister (or anyone). This is clearly insurance fraud. The above situation is as well because it has all the potential for this, even though this hypothetical may not actually be happening. (This obviously compounds the safety issue as well).

Does this often happen with heart medication? Occasionally. You can imagine the various classes of medication this definitely does happen with, though, and where monitoring for is of higher priority.

Again, is this something anyone is super interested in policing for heart medication for the elderly? Unlikely you’d even know if the patient / physician didn’t tell. As a former pharmacist who now works for an insurance company, I’m telling you why it is fraud. I can also tell you having had to go through jurisprudence and take pharmacy specific law exams for licensure, intentionally looking away is, in fact, a legal (and ethical) violation (unless you are paying cash or something). Agree or not - that’s your call, but irrelevant to where you’d stand with the BoP/DoI. Do with the information what you will, I’m neither condoning nor condeming - just stating where it stands from behind the counter.

 

[pnewton]

OK, but would you agree you aren’t upholding your end of the contract?

Only if a contract that one agreed to specified this was not permitted would it be violating a contract. That is what a contract is.

Supplying another person is a different issue.

 

[JSSD]

Only if a contract that one agreed to specified this was not permitted would it be violating a contract. That is what a contract is.

Supplying another person is a different issue.

The patient and the physician are intentially and deliberately deceiving the pharmacy, the pharmacist, and the 3rd party when they change the script in a way that allows one to gain, in this case more medicine for the same amount of money or the same amount of medicine for less money without alerting them to this change. That’s what fraud is.

It usually is spelled out in the tiny print of the multiple pages of EoB/EoC that no one reads. Again, the reasons for this are multiple and not exclusively financial. Legally, neither the physician nor the pharmacist are allowed to alter a script to say one thing and tell a patient to do another for financial gain if a 3rd party is involved. That is what you have here. Is anyone being hurt? Maybe, maybe not, but the potential is certainly there.

 

[pnewton]

The patient and the physician are intentially and deliberately deceiving the pharmacy, the pharmacist, and the 3rd party when they change the script in a way that allows one to gain, in this case more medicine for the same amount of money or the same amount of medicine for less money without alerting them to this change. That’s what fraud is. .

Again, I do not agree, but then we each must abide by our own conscience in such matters. I do not even agree that it meets the legal definition of fraud. I would bet that not one person has every been convicted for it.

 

[JSSD]

Again, I do not agree, but then we each must abide by our own conscience in such matters. I do not even agree that it meets the legal definition of fraud. I would bet that not one person has every been convicted for it.

With all due respect, it isn’t at all true for me that as a pharmacist I get to follow “my own conscience.” The law is, in fact, quite clear on this I assure you. The law is what I have to follow. That is included in your jp training/exam. Every company I have ever worked for includes it on annual corporate compliance training.

Now, has someone been convicted of not picking up their script “on time?” How do we know it isn’t non-adherence? Or they can’t afford it? Or they can’t get a ride? That happens constantly, and certainly more often than insurance shenanigans. That’d be your obvious “out” in this case above unless there is some gross evidence otherwise.

But INTENTIONALLY writing for a double dose and not disclosing it while using benefits? If I knowingly go along with it, or if a physician writes for it with that intent? Definitely not going to fly, legally. Or morally / ethically with me. Do the thought exercise and take this one further. If this is OK, why not a quadruple dose and get a full year’s worth? Are you fine with that? Are you OK with the physician writing QID for a BID drug? These are all the same thing. $0.02 If you still think it is OK, ask your own physician to write for double the number of times you need to take a drug (for any you make take) and see if they are willing.

Last point: I’d honestly be a little concerned if it didn’t bother your conscience to knowingly deceive. This is yet another reason why health care costs are so high.

 

[pnewton]

With all due respect, it isn’t at all true for me that as a pharmacist I get to follow “my own conscience.”

But I am not a pharmacist.

Perhaps you missed the first post. Your examples do not pertain to it. The question is whether one is obligated to get a new prescript. Of course when time comes for a renewal, any doctor will write the prescription correctly. For him to do otherwise would be dishonest.

If this was pain medication and pain subsided to where less was needed, should the patient have to either take the full prescribed dosage or go get a re-write for a lesser dosage? Sometimes those meds are written PRN, but not always. Yet there is no deception for backing off one’s dosage.

Last point: I’d honestly be a little concerned if it didn’t bother your conscience to knowingly deceive.

Begs the question. If there I no lie and no one I am trying to deceive, then I am not knowingly deceiving anyone. My conscience is clear in the matter. I know how hard it is for some people not to convert someone on every point of disagreement, but it is best to accept that people will disagree with you.

 

[JSSD]

I’ll just magenta out the condescension and decline to participate myself.

But I am not a pharmacist.

I’m sorry to say that this is irrelevant to the question as asked, or to the legal aspect brought up. $0.02 The OP herself questioned this in a morality forum, probably by an itch of the conscience. In other words, she knows full well she is refilling a prescription that is no longer the correct patient instructions, sig, etc, but continuing to use the prescription benefit based on the old order. That isn’t a lie or intention to deceive? Why ask? I am offering professional opinion that to do so, is in fact, technically fraud. Of course I’m happy to respectfully disagree with you on this. Do what you will, but in my world working in insurance, there really isn’t anything subjective about it.

Perhaps you missed the first post. Your examples do not pertain to it. The question is whether one is obligated to get a new prescript. Of course when time comes for a renewal, any doctor will write the prescription correctly. For him to do otherwise would be dishonest.

My examples are identical situations to the first post. $0.02 Are we just “trying something” to titrate, or is this the new dose? If the physician is truly changing the dose, all files really should to be updated for obvious safety reasons: you don’t practice in a vacuum. This includes the prescription on file. And if you’re trying to fill 180 days at a time, how many renewals are you going to get @ 90 given they’ve already picked it up and it only lasts a year? Maybe 3 more if you’re dishonest, and probably less if you’re titrating? What are you trying to do here? You don’t even have to make the call yourself.

If this was pain medication and pain subsided to where less was needed, should the patient have to either take the full prescribed dosage or go get a re-write for a lesser dosage? Sometimes those meds are written PRN, but not always. Yet there is no deception for backing off one’s dosage.

PRN is a perfectly fine sig, but you still have to include a quantity and this is a far less analogous situation to examples I provided above. Nor is this a PRN situation. Of course there is no deception in changing a dose (to set up your strawman), but continuing to refill the wrong order when you know otherwise is deception, potentially with the intent of gain.

Begs the question. If there I no lie and no one I am trying to deceive, then I am not knowingly deceiving anyone. My conscience is clear in the matter. I know how hard it is for some people not to convert someone on every point of disagreement, but it is best to accept that people will disagree with you.

As I said in my first post in this thread - do what you need to do. I certainly never put any effort into sniffing out and hunting this sort of thing down, especially in regards to a heart medication. $0.02 But if someone like Veronica97 came to me and TOLD me how things are changing, well of course I’m on the phone getting a new script. It is malpractice and negligence to do otherwise. It is also potentially dangerous.