Medication Policy &
EPCS (electronic prescription of controlled substance)
>> If/when medication is recommended, you can expect an explanation about what it is for, how it works, benefits and risks, possible side effects, and any signs and symptoms to report.
>>Once stabilized on a CII medication, I may give you 3 one-month scripts or if your insurance permits, 1 ninety-day script.
>> Once you are on medication, it is crucial that you report any major changes in your mental status and/or physical health, including pregnancy and any new medications prescribed by other clinicians. If you wish to discontinue any medications, it is important to inform me, as some medications should be tapered slowly.
>>KNOW THAT OBTAINING A CONSISTENT MEDICATION SUPPLY WILL BE THE MOST CHALLENGING BUT CRUCIAL ASPECT OF YOUR TREATMENT. EXPECT PROBLEMS AT EVERY STEP IN THE PROCESS. ANTICIPATE DELAYS AND PLAN ACCORDINGLY, by making timely appointments with me (4-6 weeks early is recommended); allowing me time to solve problems and obtain Prior Authorization for payment for medications; and expecting that your pharmacy may not have sufficient supply of your medication, requiring me to send an order to another pharmacy. And as I will be mailing you prescriptions and Superbills, please define a system for managing your mail.
>>Controlled substance prescription history is recorded in the Colorado Prescription Drug Monitoring Program, and may be accessed by authorized individuals (DEA-licensed clinicians and DEA officials). Every State has such a System, and there is reciprocity between States that make all controlled substance records accessible. This System exists to partially address problems of prescription drug abuse.
>>I expect that you will not alter a paper prescription or give away, sell, or otherwise divert medication I prescribe for you; violation of this policy is a Felony and you will be discharged from my care.
>> The Federal DEA writes and enforces regulations for controlled substance medications. Each medication is in a Class with a Roman numeral that denotes the level of control, ie,
C II: Includes narcotic pain relievers and most medications used for ADHD treatment. These can be electronically sent directly to a pharmacy (see EPCS, below) or written on paper and presented to the pharmacy in person. No phone or fax'd prescriptions are permitted. If you accept a partial fill of a C II medication, you cannot return to the pharmacy later and obtain the remainder, rather, you need to contact me, I need to verify that you received a partial fill, and then I can send a new prescription to make up the difference. "Refills" of CII drugs are NOT permitted; this means 3 one-month fills, with effective dates specified (as below), OR a 90 day fill if/as permitted by your insurance company.
C IV: Includes some drugs used for anxiety and insomnia. Refills permitted, meaning that with one order I can send a one month supply that can be refilled; your pharmacy will keep the refill order on file.
>> I am required by Law to write "do not fill before x date" on CII prescriptions. Pharmacies are also required to comply with the same Law. The date on your current bottle, NOT my written script actually determines when the next fill can be released. If in doubt, call your Pharmacy.
>>I will not replace lost or stolen controlled substance medication. Safeguard your supply carefully, just as you do your money.
>>Prescriptions for controlled substance stimulants cannot be filled outside of Colorado (except for mail order pharmacies located outside of Colorado).
>>When you travel with controlled substance medication, always keep it in the prescription bottle. I recommend that you only bring the supply needed for your trip and leave the remainder in a safe place at home.
>>If travelling internationally, check the US State Department for an A-Z listing per Country, and Google, to ascertain if controlled substances are permitted in that Country. If so, it is prudent to also carry a letter written by me. Japan does not permit Adderall but does allow Ritalin.
>>If you are travelling out of Colorado and thus needing your medication earlier than next effective date, email me to request a new prescription. Return the unwanted prescription by marking it VOID in big bold caps, take a photo of it with your smartphone and email it to me. Then tell me your travel date . If an e-script is needed, confirm what pharmacy you want it sent to (pharmacy name, address & town).
>>If toxicology screening is required by your employer, school, or probation officer, your screen will show positive results for the prescribed controlled substance(s). Before arriving at the testing station, ask them what documentation you need from me to verify that you are on a prescribed controlled substance. Sometimes your prescription bottle is proof, sometimes a letter from me is required. Do not involve your Employer or School in this matter, as your diagnosis is HIPPAA-protected information and the testing lab is required to maintain confidentiality in their Report.
>>Generic medications are required by most insurances because of their lower cost. The purity of generics, however, may vary up to 20%, according to FDA Standards. With regard to stimulant medications used for ADHD, there are multiple companies licensed to produce generic medications. The name of the manufacturer is written on every prescription bottle, after the letters MFR (manufacturer). If you receive a generic that is not working like previously, contact me so we can resolve the problem. You may have received product from a different manufacturer, or same manufacturer but different production run. I may direct you to increase/decrease dosage of existing supply by 20%, and this may require an earlier fill date for the following month. Complicated...
RE: PRIOR AUTHORIZATION FOR PAYMENT FOR MEDICATIONS
>>Prior Authorization is your insurance company's requirement that I obtain their authorization for payment of medication. It is required by some insurance Plans. While they say it is for matters of safety or quality assurance, I can only conclude otherwise: it is their attempt to erect barriers to payment. Prior Authorizations for medication did not exist ten years ago. As the cost of medication has risen, so has insurance companies' resistance to paying for it.
>>When your pharmacy tells you Prior Auth is needed, I will not know that unless you email me and tell me that. This is what I need from you: a front + back copy of your insurance card(s)--sometimes there are 2 cards, one for clinical care and one for medicatiions. Sometimes they will issue new cards with new id #s every year, so if you send me last year's card it is a wasted effort.
>>When PA is granted, it is usually for one year, then needs to be renewed if you remain on the same policy. When I obtain PA for you, I will provide the PA reference # and expiration date to you; note this date on your calendar and contact me 2 weeks in advance to request PA Renewal , to ensure a steady stream of paid-for medication. If/when your insurance coverage changes, new PAs are needed. Most people change insurances in January or July. This means I can have hundreds of PAs to complete in January; they get done in the order requested, and patience is appreciated.
>>Prior Authorizations are deceptive and complicated, as often 3 things are being authorized--the medication itself, the dosage, and how many units of medication needed per month. Insurance companies often have caps on dosage and quantity that are lower than what is needed. Solutions: pay out of pocket for what they will not cover, or consult with me to find a solution covered by them. Check for real-time pricing of your meds in you zip code
>>Know that if you are waiting for Prior Authorization, you have the right to pay for your prescription and can then seek reimbursement afterwards. Exception: recent Medicaid policy change will not permit this.
>>RE: EPCS (Electronic Prescription of Controlled Substance)
C-II prescriptions cannot be phoned in. I am able to electronically prescribe controlled substance medications directly to your pharmacy, OR you can present a paper script to the pharmacy. EPCS takes only 5-10 minutes to deliver, and eliminates the problems of lost/misplaced/stolen paper prescriptions, fraud, and forgery. BUT Colorado pharmacies will not keep CII e-scripts on file for more than 2-3 days. So with each followup appointment, I will send all 3 scripts I may give you by paper in the mail, or one script electronically and 2 by mail, your choice. But if your pharmacy has no supply, an EPCS order must be sent by me, so having all your scripts on paper eliminates this step and you can just take it to another pharmacy. Complicated...
Here is the EPCS procedure:
1) I need to know pharmacy name and full address (not their phone number). I verify this during each appointment. I also verify your mailing address. If you have moved, you must also notify the USPS (in person or online) of your change of address. Failure to notify USPS usually means my mail to you is returned to me, an inconvenience to us both.
2) Prescription sent. This usually takes a few minutes, but sometimes there are transmission problems.
3) Call your pharmacy before you go and ask if/when ready for pickup. If there is a delay, inquire why. Sometimes it is a Prior Authorization issue (see above). Sometimes they can't find your script; know that EPCS scripts arrive at the pharmacy in a separate cue than non-controlled scripts and you should tell them that. Sometimes the pharmacy has no supply in stock, a common problem requiring a 2-3 day wait. Sometimes there are regional shortages of supplies, an even bigger problem, requiring you to call multiple pharmacies until you locate a supply.
4) If you encounter other problems, email me. Remember that Pharmacists uphold all DEA, Federal, and State Regulations, and are professionally obligated to question prescriptions, your identity, and my clinical judgement. Many are as poorly informed about ADHD as the rest of the general population, and so we must politely educate them and combat any bias. Also know that the clerks who man the counter are sometimes not fully informed about the many rules and regulations pertaining to controlled substance medications; you should always exercise your right to speak to the Pharmacist on duty if you think the clerk answering the phone is mis-informed.