Community Pharmacy and the Donut Hole

The other day one of our patients of many years was picking up a prescription.  "$599", she exclaimed at the pharmacy counter.  "I didn't pay that much last time", she continued.  After a short bit of pharmacy computer forensics, we concluded that all year long she had been paying $90 for a two month supply, last time she picked the prescription up she had paid $197 and yes, this time the total was in fact $599. 

The historical review of the computer records disclosed to us that our young lady had in fact moved 100% into the Medicare D coverage gap, sometimes referred to as the donut hole.  The previous prescription for $197 was her partial entrance into the coverage gap, and this prescription was 100% attributable to crossing part of the broad stretch of the donut hole.

So now what do we do?  During this time of year, late summer too early fall, we come across this particular situation quite often.  Seniors have been paying their co-payments all year long and then all of a sudden they enter into the Medicare D coverage gap.  This is the portion of the Medicare D program where they are responsible for the majority of the cost of their medications.  Over the next few years the coverage gap is being faded out; however, for now, it is still a significant "chunk of change" for quite a few people.

I have come to realize that most seniors do not think about or plan for the coverage gap.  When they show up at the pharmacy and see that their prescription is five times what they paid last time, they are always very surprised and need an explanation of what is going on.  At this point, we take the time to explain the Medicare D coverage gap process.  There is always an "Oh, now I remember" moment in the discussion where the customer remembers the "donut hole" and we proceed to work through the transaction.

With this particular transaction, our young lady was very pleasant; however, the cost of $599 was definitely throwing up a road block.  She was very well aware of the importance of this particular anti-arrhythmic medication.  She understands her care and is quite knowledgeable about how important it is to continue therapy without missing any doses.  We decided to re-process the prescription for only one month, rather than two and then take it from there.

Well, one month of the medication processed out to $300, and this was still a bit ominous for the young lady after she began to think that she would need to do this for two more months, at which point the Medicare D program will reset and start over at the first of the year. 

After a bit more consultation, we discussed the option of contacting the physician about changing from the sustained release form of this medication to the immediate release form.  She explained that the physician had discussed this with her in the past; however, she stated it had been much more convenient for her taking a pill twice daily rather than needing to fit a dose in every 8 hours.  It is interesting that with this particular medication, the sustained release form of the medication costs upwards of 10 times more than the immediate release form.   She agreed that, for the difference in cost, she would be more than happy to adjust her schedule to accommodate an every 8 hour dosing regimen.

Being after five on a Friday afternoon, the physician was not available for immediate consultation, so I explained the situation in writing and sent a fax off to the physician.  The customer agreed she would call the physician Monday morning and discuss the situation with him also.  If the physician agrees and authorizes an order, we will process a prescription for her next week for the immediate release form of the medication.   We then reprocessed the current prescription for seven days of the medication which came to an acceptable $70.

At this point, with three or four pharmacy customers standing behind her at the counter, she exclaims, "I'd like to see someone try and go through this process down at XYZ Big Box Pharmacy, this is why I come to My Community Pharmacy".   Immediately after, the customer standing next to her stated, "These guys are great, I love this pharmacy".   

Yes, working in community pharmacy definitely has its challenges; however, it is moments like these that help make it all worthwhile!


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Adherence, Health Literacy & Medication Education

A study I just reviewed from the September, 2013 edition of the New England Journal of Internal Medicine shows that nearly 72% of patients picking up prescriptions have some sort of Health Literacy limitation.  (If you are unsure of what Health Literacy is, please review this article.)  Of those 72%, approximately half of the patients were not adherent to their medication regimen.   

Perhaps, just maybe, we need to take a closer look at how patients and caregivers receive their medication education. 

There are many venues in which patients receive medication education.  Some are better than others.  When receiving medication information we need to consider a few different items:

1.       What is the source of this information?
2.       Is the information being presented to me in a format that I can understand?
3.       Will I be able to refer back to this information whenever I need?
4.       How do I get my questions answered after reviewing the information is presented to me?

 Some of the methods that patients receive medication information are as follows:

·         Medication information is presented to the patient by the prescriber when the prescription is written.
o   Pros:  Patient is attentive and captive in the office.
o   Cons:  Patients usually forget what prescriber says soon after leaving the office.

·         Prescription counseling info presented to patient at pharmacy counter when picking up prescription:
o   Pros:  Pharmacist does the counseling and hopefully discusses all of the important information necessary.  Pharmacist also hands a drug information handout for follow up. 
o   Cons:  Sometimes pharmacist is busy and hurry’s through session.  Again, patient will regularly forget most of what the pharmacist says by time they get home. 

·         Drug Information Handout:
o   Pros:  These informational handouts are very complete.  Now and again I come across a patient who takes the time to read them front to back and they always call with questions.  This is ideal.
o   Cons:  These handouts are long, boring and cumbersome; rarely will a patient read them front to back and call with questions.

·         Drug information from an internet search:
o   Pros:  Information is right there, ready for your review.  Information is abundant and 1000’s of sources available.  Studies, evaluations, monographs, institutional sites as well as a never ending supply of personal testimonials.
o   Cons:  How in the world do you discern what is credible information.  You need to know and trust your source and you need to take the time to do appropriate research.

·         Friends telling you what to do:
o   Pros:  What could be better than following the advice of a friend?
o   Cons:  Really?  We are talking about your prescription medications here!

·         AudibleRx Web Membership or Android/IPhone  App:
o   Pros:  After having a consultation with your pharmacist at your community pharmacy, you then listen to a 6-8 Medication Specific Counseling Session.  After listening, you will have a clear idea of what you do and don’t know about your medication and be in a position to take educated questions back to your own pharmacist or doctor.
o   Cons:  You need to invest 6 minutes of your time to listen to the counseling session.

Regardless of your method of medication information, please take the time to follow through and do it.  Health Literacy is the concept that patients will understand their own basic health care knowledge.  Understanding your own medications; why you are taking them, what are the consequences of not treating, and where to go for more information are all important aspects of your own Health Literacy.

If you ever have a question about your medication, pick up the phone and call your community pharmacist.  If you don’t have a community pharmacist to contact, get one!  Mail-order prescriptions have done quite a bit to deter patients from having their consults with their own community pharmacist.  I encourage everyone to take a look at their program and see if it is possible to once again begin picking up their prescriptions from their local pharmacy.  When your community pharmacist is filling your prescriptions, the pharmacist is in a much better position to answer your medication related questions.

The above examples of how to receive medication information may all have a place in your education process; however, every patient needs a specific process for verifying and validating their information when they have questions.  Know your source, and know where you are going to call to get your questions answered.


Please take a moment to comment and tell us what your source for medication information is.

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What is Health Literacy?

Understanding basic health information includes (but not limited to):
  • Knowing your diagnosis and being able to describe it in one or two sentences.
  • Understanding your medications, why you are taking them, what to look for, which  diagnosis they correspond to, cautions, what to do if you miss a dose, etc…
  • What are the short and long term consequences of not treating your diagnosis?
  • Who do you call for questions about your health care or medication questions?

Copyright AudibleRx (TM), all rights reserved. Please do not copy or publish or distribute without consent and approval from AudibleRx (TM).

AudibleRx App

“The pharmacy profession has accepted responsibility for providing patient education and counseling in the context of pharmaceutical care to improve patient adherence and reduce medication-related problems.”

With that statement in mind, AudibleRx is proud to announce that it has finally released a smart phone/tablet application complete with all of the 200+ Medication Specific Counseling Sessions.  The app for Android is available today, and the app for IPhone will be available in the very near future.

The app's are being offered for FREE to individual users:
Please pass it on!

PERSONAL USE ONLY: This application is for personal use only and is not to be used for institutional training. AudibleRx offers institutional patient education programs. Please contact AudibleRx for more information.

DISCLAIMER: These recordings are meant to supplement your knowledge and understanding of your medications and are not a replacement for counseling with your pharmacist or doctor. AudibleRx maintains no liability for your medication education, understanding or usage. This information does not allow you to take a prescription medication that was not prescribed for you. AudibleRx has performed extensive review of each topic to assure the information provided is current and relevant; however, AudibleRx maintains no liability for and can not guarantee the accuracy of the information provided in the recording sessions. Talk with your pharmacist or doctor before taking your medication and if you have any questions regarding your medication.


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Dangers of Stopping Psychiatric Medications Too Soon

Dion Short Metzger, M.D. is a board certified adult psychiatrist whose approachable demeanor, determined spirit and caring attitude have allowed her to have a valuable impact on her patients.  Many people are unaware of the problems they may face if they stop or decrease their psychiatric medications without the approval of their physician.  Dr. Metzger graciously wrote a Guest Blog for AudibleRx discussing the dangers of stopping psychiatric medications too quickly.  Please take a moment to visit Dr Metzgers web page, like her on facebook or follow her on twitter. 

There are many reasons why a patient would want to stop their psychiatric medications including experiencing unbearable side effects, not feeling like it’s working or not believing that they need to take it anymore.  These reasons are warranted and it is always recommended to discuss this with their physician first before making any changes. Many patients are unaware that stopping their medications “cold turkey” could have adverse effects. This is why it is always important to talk to their doctor regularly about how their medications are doing, whether the report is good or bad. This is my go-to list of commonly prescribed medications that require a taper (a slow decrease of the dose to discontinue) to prevent withdrawal symptoms and/or worsening of psychiatric symptoms.


Þ    Anxiolytics

o    Alprazolam (Xanax-TM), Diazepam (Valium-TM), Clonazepam (Klonopin-TM) and Lorazepam (Ativan-TM)

§  These medications are also known as benzodiazepines and need to be carefully tapered by a physician. If stopped abruptly, withdrawal symptoms can include weakness, nervousness, tremors, insomnia, and seizures. It can take anywhere from 4 weeks to several months to discontinue these medications, depending on the dose.

Þ    Antidepressants

o   Venlafaxine (Effexor-TM), Duloxetine (Cymbalta-TM), and Desvenlafaxine (Pristiq-TM)

§  These medications are in a class called SNRI’s (Dual Serotonin and Norepinephrine Reuptake Inhibitor) and have more severe withdrawal effects, as compared to other antidepressants. It is usually best to taper these medications over 4 to 6 weeks. If stopped too soon, a patient can experience headache, vomiting, electric sensations (described as feeling similar to static shocks), sweating and irritability.

Þ    Mood Stabilizers

o   Lithium, Lamotrigine (Lamictal-TM) and Divalproex Sodium (Depakote-TM)

§  The important thing to know about these medications is that abrupt withdrawal can lead to quick relapse of mood changes in bipolar disorder and depression. This also can possibly increase the risk of suicide.

Þ    Antipsychotics

o   Quetiapine (Seroquel-TM), Risperidone (Risperdal-TM), Aripiprazole (Abilify-TM) and Olanzapine (Zyprexa-TM)

§  Similar to the mood stabilizers, there is a risk of having a severe relapse of psychotic symptoms such as hallucinations and delusions if these medications are stopped too soon. It is recommended to slowly lower the dose over 6 to 8 weeks to stop, especially when switching to a new antipsychotic.


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