The Prescription

1. 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.

2. The Elements of the Prescription • Patient’s name • Prescriber’s name, address and phone. • Date it was written • Name, strength, and quantity of drug • Directions for use (sig) • Signature of the prescriber (very important) • Route of administration • Refills

3. Controlled Substance Prescription • In addition to the above elements, the following is required as well: • Patient’s and Prescriber’s address • Prescriber’s DEA number

4. 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 CII-CV can be sent electronically. • Section 6810 states that in addition to the signature, the stamped or imprint name of the prescriber must be on the prescription

5. 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.

6. 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.

7. 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

8. 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

9. 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.

10. 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.

11. 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 red “C” in the lower right corner in one drawer and all other prescription in second file. • Option 3: CII in one file with CIII-CV/other legend drugs in second file. CIII-CV must have red C in lower right corner

12. Prescription Transfers • A refill(s) may be transferred from one pharmacy to another either in the same state or different states. • A pharmacist is to handle Rx transfers. • Federal law permits the transfer of all the refills on a prescription provided that amount transferred does not exceed the total number of refills remaining. • In NY only one transfer at a time is allowed. • The pharmacist that transfers the refills must do the following documentation: • Document the pharmacist he/she spoke with • Name, address, DEA, and the NABP# of the pharmacy transferred to • VOID that original prescription • The receiving pharmacist must document: • Pharmacist spoken with • Name, address, DEA, NABP# of the pharmacy transferred from • All the information on the original prescription with the old pharmacy Rx number • Must write “TRANSFER” on the face of the prescription • Federal Law allows transfer of controlled substance Rx in schedules III-V on a one time basis • NY does not allow transfer on CIII-CV

13. Federal Law on Retail Prescription • Federal law provides many means for prescribers to issues prescriptions • Written • Electronic (even for controlled substances)but NOT in NY • Fax • Telephone • 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) • If Patient requests a partial fill; the balance cannot be fill later; the balance is void

14. C3-C4 • 30 days only maximum • 5 refills or 6 months life • C5 (Federal Law) • Codeine containing cough syrup must be combined with other med and be no more than 2 mg/ml codeine • opiates in small amounts combined with a noxious drug to prevent abuse (diphenoxylate 2.5 mg/Atropine 0.0025 mg) • Depending on state law can be dispensed without a prescription • Patient must be 21 or older • Sale by pharmacist mandatory • Log book maintained • Max of 120 ml in 48 hours of a codeine containing product or 24 dose units per 48 hours per patient of solid dosage products • 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 • Must know prescriber in good faith • If any are in question, can and should refuse to fill

15. Exceptions to the 30 day rule for 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 up to 60 days. Fax copies are permitted in these cases but pharmacist must write “LTCF patient” or “terminal” patient on the face of the prescription

16. Medication Orders in the Hospital • An order usually contains patient name, DOB, and MRN. • Patient’s Diagnosis, Allergies, Location in Hospital • Patient’s height and Weight • 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.

17. Depending on State Law, a physician or other prescriber may call in a verbal order to the institution’s pharmacy as an emergency measure. • This is called a Emergency Verbal Order • This is called to help speed up the processing of the medication • Example: Alteplase Injection. 100 mg/100 ml of Sterile water for injection. IV infusion over a 60 minute hang time • A written order is followed up

18. Types of Institutional Medication Orders • Routine orders- Daily order that are order on an ongoing basis. Example: Enalapril 10 mg Daily • STAT orders- orders that are needed as an emergency measure. i.e. Dilitiazem 5 mg IVP X 1 • PRN- as needed order- ordered as per patient request • i.e. Percocet 1-2 tablets q4h PRN for pain