Pharmacy Technician Career Environments

1. Pharmacy Technician Career Environments • Retail Pharmacy • Retail pharmacy, also know as community based pharmacy or community pharmacy, is a very common environment in which pharmacy technicians are employed. These pharmacies provide prescription services and an outlet for the sales of commonly purchased good and services. • Retail pharmacies consists of independent pharmacies and chain pharmacies. • In general, the major benefit of retail pharmacies is accessibility. Often the patient will go to see the pharmacist at a retail store first before seeking medical attention for which they may have limited access to or no insurance to help cover the costs.

2. Independent Pharmacy • Owned as a sole proprietorship by one or a few owners. • Provide prescription filling along with other ancillary services (surgical supplies, vitamins, hallmark®) • Often provide personal services • Major benefit: familiarity of the pharmacists with the customers • Disadvantage: may not have the pricing power of larger chain stores.

3. Chain Drug Stores • National franchises like Walgreen’s, CVS, Rite Aid, and Duane Reade (east coast) have many stores around the US and/or in a regional area • Offer convenience with many stores operating 24/7 • Major advantages: pricing power, convenience, and accessibility. • Disadvantages: lack of personalized service between pharmacist and patient.

4. Retail Staff • Supervising pharmacist: a full time pharmacist who is in charge of the legal and administrative aspect of the pharmacy • Store Manager: a person, who may or may not be a pharmacist, that is in charge of the operation of the store in general • Typically the store is divided into front end and back end. • Front end deals with OTC issues and other non medication issues a customer may have • Back end contains the pharmacy • Stores the legend medications • Stores other restricted meds and higher priced devices • Blood glucose strips, blood pressure monitors, Plan B, and products that contain pseudoephedrine. • Combat Methamphetamine epidemic act of 2005 requires removal of pseudoephedrine products from the public area and mandates record keeping with the per transaction limit of 3.6 grams per patient.

5. Regulatory Agencies • State Boards of Pharmacy regulates the practice of pharmacy which in NYS are contained in the education law of the board of regents article 137, the public health law article 33 for controlled substances, and the NYSRR title 10 among others. SBOP conducts inspections of pharmacy facilities. • Centers for Medicare and Medicaid Services: CMS regulates the federal programs of Medicare and Medicaid along others. CMS conducts inspections to ensure compliance with federal regulations. • Third Party Payers: Third party insurance companies also may conduct inspects of pharmacy establishments to determine if contractual agreements are kept between insurance payer and the pharmacy.

6. The Prescription • The pharmacy technician is often the first person to examine the patient’s prescription for completeness and other issues. • Due to this it is very important that a pharmacy technicians understands the basic elements of the prescription to save time and to ensure customer satisfaction. This is probably the technician’s primary function in the retail setting.

7. The Elements of the Prescription • Patient’s name, address, and age. • Prescriber’s name, address and phone. • Date it was written • Name, strength, and quantity of drug • Directions for use • Signature of the prescriber (very important) • Route of administration • Product selection permitted (if brand or generic permitted)

8. Probably the most important element on the prescription is the signature of the prescriber. Whether electronic or hard copy the signature must be there for the prescription to be valid. • In NYS, according to article 137 of the education law 6802 electronic prescriptions are allowed in NYS. An electronic prescription is a prescription that is created and generated by the prescriber and sent electronically (E prescribing). Prescriptions for controlled substances are not permitted to be electronically generated in NYS; however under federal law CIII-CV can be sent electronically. In all cases CII can’t e-prescribed • Section 6810 states that in addition to the signature, the stamped or imprint name of the prescriber must be on the prescription

9. In NYS, the pharmacist is permitted to clarify and enter data on the prescription to include all information with the exception of the signature. If a prescription is filled without the signature the pharmacist will be guilty of professional misconduct under Part 29.7 of the board of regents. In addition, the date can’t be added on an Rx for a controlled substance • If the patient’s information and/or the prescriber’s information is readily retrievable in the pharmacy computerized records, the physical presence of this information on the prescription is not necessary • The face of the prescription must be signed or initialed by the pharmacist with the date filled; refills must be documented on the back with the date filled along with the Pharmacist’s initials. Records of refills may be stored electronically (NYS) • Remember, CII can’t be refilled. • CIII can be refilled 5 times or 6 months • CIV and CV for 11 refills or one year.

10. Prescription Elements Continued • Other elements on the prescription may include • Prescriber’s license number and registration number • Prescriber’s DEA number (required to write a controlled substance prescription) • Prescriber’s NPI or national provider’s identification number. This is required by medicare in the filling of surgical products.

11. DEA Numbers • Any entity handling controlled substances in the US from prescribing , dispensing and manufacturing requires registration with the DEA of the US Department of Justice. • Consists of two letters A or B followed by the first letter of the prescriber’s last name following by a seven digit number. One way to determine if a DEA is fraudulent is the calculate the sum of digits 1,3, and 5 and add it to twice the sum of 2,4,and 6. The result will have a digit which should match the check digit of the DEA number, the last digit

12. NPI numbers • The NPI is a ten digit number that was created by HIPAA act of 1996. The NPI is a unique identifier that is used by CMS to identify healthcare providers for the purposes of administrative issues and reimbursements. • Often other third party payers utilize this number to file claims and payments to pharmacies. • Often an adjudication is denied because of lack of prescriber’s NPI. The NPI for various providers can be found at: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

13. Who can write prescriptions? • MD • NP • DO • DVM • DPM • Ophthalmologists • DDS • PA • Physician’s assistants can in general write for prescriptions so long as their primary supervising physician name, address, and registration number is on the prescription. Often the PA will use his/her physician’s prescription blank so long as the PA signs the Rx and stamps his/her name on it with his registration number. • Physician Assistants, as of 2007, can write for prescriptions for CII and other scheduled drugs. In this case he/she would use his own Rx blanks with their own DEA numbers.

14. NYS Official Prescription Program • Public Health Law 21 requires all prescriptions for controlled drugs and other legend drugs to be issued on an official NYS prescription which contains all required information on it with the NYS seal, and a serialized number on the lower right hand corner. • Issued in an attempt to discourage doctor shopping and to monitor prescription drug usage patterns in the state. • When using electronic prescribing official Rx not required.

15. Filing Prescriptions • Most states require hard copy Rx to be stored for a 5 year period. • Further federal regulations require that controlled substance Rx’s be filed in such a way as to be easily retrievable by law enforcement. • Option 1: three separate cabinets for CII, CIII-CV, and other legend Rxs. • Option 2: two drawer system: CII-CV with CIII-CV marked with a “C” in the lower right corner in one drawer and all other prescription in second drawer.

16. Prescription Transfers • A refill may be transferred from one pharmacy to another either in the same state or different states. • A pharmacist is to handle Rx transfers. • Some states allow transfer of all of patient’s Rx refills. In NY only one transfer at a time is allowed.

17. Summary of the Retail Prescription • Patient and Prescriber’s name and address • Prescriber’s license #, Registration # and/or NPI • Drugs name, strength, quantity and directions from use • Route • Specific issues (DAW or not, easy caps, etc) • Signature of prescriber • In some states, the imprinted name of prescriber must be on Rx

18. Federal Law on Retail Prescription • Federal law provides many means to issues prescriptions • Electronically (even for controlled substance C3-C5, C2 can be filled but must have written script to release to patients) • Fax copies of C3-C5 are acceptable as original (remember state law may be stricter) • Controlled Substance Rx: Federal law • C2 • No fax as original (exceptions: LTCF, Hospice, Infusion care) • 30 days only • No refill • Partial fill ok with remainder to be fill in 72 hours. If can’t fill balance in 72 hours, the balance is voided. (exception is LTCF or terminal ill patient)

19. C3-C4 • 30 days only • 5 refills in 6 months • C5 (Federal Law) • Depending on state law can be dispensed without a prescription • Codeine containing cough syrup must be combined with other med and be no more than 2 mg/ml codeine • Patient must be 21 or older • Sale by pharmacist • Log book maintained • Max of 120 ml in 4 days • Oral Controlled Substances (Federal Law) • Permitted on C3-CV (in NYS 5 days for C2, C3 and C5) • C2 emergency oral Rx • For the emergency period only ( 5 days in NY) • Must reduce to writing by pharmacist • No alternative available • 72 hours MD must deliver hard copy

20. To destroy controlled substances • Must notify DEA office and state narcotic office (NYS DOH Bureau of Narcotic Enforcement) of Day and time of destruction • DEA 41 is used to surrender drugs to the DEA directly • To report theft of controlled substances • Notify local police • Notify DEA office • State narcotic office • Fill out DEA 106 form • To order c2 drugs complete • DEA 222 form • To apply for a DEA registration • DEA 224

21. Other Technician duties • Handling Deliveries • Inventory management • Record keeping • Stock rotation and others • Remember, counseling is the pharmacist’s duties. • One area where technician can offer advise is in the use of medical devices like blood pressure monitors, glucose testing equipment, etc.

22. PCTE key ideas on Retail Pharmacy • Only Pharmacist can counsel patients, check for drug interactions, speak with prescribers and disclose HIPAA PHI to others and accept oral telephone Rx’s for new prescriptions from prescribers • Pharmacy technician can : • Physically prepare medications (remember exceptions) • Prepack medications • Gather medical information from patient • Key in data in pharmacy computer system • Physical Inventory of controlled substances every 2 years (Federal law) • FDA is charged with protecting the public by enforcing FDCA • Adulterated drugs’ strength and purity subpotent • Misbranding drugs have labels that can not true in fact to what is in the container. Also, if the name and place of manufacturer not on label. If a drug is a habit forming drug and is not stated on the label its misbranded

23. All dispensed prescriptions must comply with the poison prevention packaging act of 1970 • Child resistant caps on all dispensed vials • Except when patient or prescriber requests non resistant caps (i.e easy caps) • Excepted drug (i.e Sublingual Nitroglycerin) • Patient Package Inserts (PPI) • Must be given to patients when dispensing in retail setting • FDA governs this • Drugs that require this: • OC • Estrogen and progesterone products • Isotretinoin • Inhalers • OSHA Pharmacy requirements • MSDS for hazardous substances • Flammable agents (alcohol) in a non flammable environment

24. Exceptions to the 30 day rule to controlled substance prescriptions • With certain medical conditions state law permitted greater than 30 day filling of Rx • Code A= panic disorders • Code B= ADHD • Code C= neurologically (seizures) • Code D= Pain relief in incurable conditions • If a patient is a resident in a LTCF or a terminally ill patient then a C2 prescription may be filled for upto 60 days. Fax copies are permitted in these cases but pharmacist must write “LTCF patient” or “terminal” patient on the face of the prescription

25. Health System Pharmacy • Pharmacy setting where patients reside at the facility where the pharmacy is located • Includes acute care hospitals • Long term care facilities-provides skilled nursing services to patients in need of long term rehabilitative services • Hospices-facilities that provide end of life palliative care to terminally ill patients. • Nursing Homes-facilities that provide skilled nursing care to elderly people who can no longer care for themselves due to chronic illness • Correctional Facilities-prisons

26. Hospital Staff • Includes pharmacists, nurses, physical therapists, respiratory therapists, nutritionists, etc • DO- doctor of osteopathy is a medical doctor that can practice conventional medicine and tends to use musculoskeletal manipulation to assist the patient. • MD- doctor of medicine who practices conventional medicine. • Physician Assistant- a licensed individual who is trained to work with and under the supervision of a physician in the care of patients. • Nurse Practitioner- a licensed individual who has rights similar to a physician assistant • RN- a licensed individual who is trained to provide and administer medical therapy (including medications) to patients under the order of a DO or MD • LPN- similar to an RN, however, works under the supervision of an RN. • Certified Nursing Assistant- CNA works under the supervision of an RN; however medication administration is not allowed

27. Regulatory Agencies in the Hospital • Joint Commission on the Accreditation of Healthcare Organizations • Called Joint Commission or JCAHO for short • Provides accreditation to hospitals, Long term care facilities and other organizations • Site inspections conducted every three years • Passing of site inspections required for accreditation • Accreditation required for CMS funding by the government

28. State Board of Pharmacy • State board of pharmacy typically monitors community pharmacies; but in the hospital setting monitors the staff in the hospital and not the department as a whole.

29. State Health Departments • State health departments directly governs hospitals, including the pharmacy department. • Directly charters a hospital and grants its privilege to operate in the state.

30. Medication Dispensing System • Floor Stock Distribution. A system where a complete compliment of medication inventory is keep at the nursing station. System is prone to diversion and is not used anymore in most hospitals, except in cases of ADC. • Unit Dose System: A system where a unit of medication is dispensed for a 24 hour period to a patient at any given time. System is more common and discourages diversion. Prepacking works hand in hand with such a system.

31. Medication Orders in the Hospital • An order usually contains patient name, DOB, and MRN. • Date and hour the order is written. • Name of Drug, dose, frequency and if routine, STAT or PRN. • Route • Name of the prescriber and the pager • Can be a paper order sent to the pharmacy or an order entered into a CPOE.

32. Pharmacy Technician’s Duties in the Hospital • Data collection (information on drug turnover and usage) • Survey and inspections (nursing station inspection) • Education (training new technicians) • Maintenance (restock of omnicell and pyxis, monitoring and replacement of crash cart items) • Dispensing/inventory management (assist with preparation of drug products, and in some states parenteral medications)

33. Prepackaging of medications • An operation in which a medication in bulk is processed into a smaller unit by the institution. • Works well with a unit dose system • Normally in most states once a medication is dispensed a pharmacy is prohibited from placing the medication back into stock if the dispensed drug is returned. • If a drug is dispensed in a tamper resistant prepacked blister pack (in case of tablets) then the medication is permitted to be put back into stock. • Thus prepacking is a very cost efficient process • Normally done by pharmacy technicians and checked by pharmacists. • Most states provide a guideline of a one year maximum expiration date or 50% of the lapsed time to manufacturer’s expiration. This dating has been shown to prevent unintentional loss of potency.

34. A word about NDC numbers • When manufacturers package their medications federal law mandates a unique identifier known as a national drug code (NDC) • Has three parts: a five digit first part which indicates its manufacturer, a second three digit part which indicates the drug, its strength, and dosage form. Finally the third number indicates its package size. • Part of the barcode on the container of the drug product.

35. Technology in the Pharmacy • Counting Machines • Uses an electronic eye to detect or count tablets or capsules • i.e. McKesson’s Baker Universal ® 2010 and Kirby Lester KL15df ®

36. Drug Dispensing Robotics • McKesson Baker Cells® and Scriptpro® 200 • Larger institutions tend to have such robots • Consists of a mechanical arm that can pivot along a track to retrieve drugs from preselected drug cassettes • Very expensive and not commonplace

37. Automated Dispensing Machines • Examples include Acudose ®, Omnicell®, Pyxis ® • Consists of medication storage area and a central keyboard terminal • Pharmacist profiles a medication for a patient which is electronically transmitted to the ADM or ADC. • Nurse retrieves the medication at the required time and helps to decrease TAT. • ADC are very cost effective and helps to maintain inventory and assists with billing by charging issues and crediting returns

38. Bar Code Systems • Provides for medication checks to increase medication safety. • Bedside Bar-coding act as a final check in the medication verification process. RN scan the barcode on his/her ID badge, then scans the patient’s wristband ID barcode and finally scans the barcode of the medication’s packaging. • The transaction is recorded in the patient’s MAR. • Ensures the five “rights” of medication administration • commonly used systems are Intellidot ® and Patient Safe Solutions ®