Medication Order Entry and Filling

1. Medication Order Entry and Filling • Pharmacy Technician Tasks • Accepting new prescriptions from patient • New telephoned prescriptions in some states, NY included, are not permitted to be accepted by pharmacy technicians • Receiving refill requested from the patient • Calling doctor’s office for refill authorizations • Collecting patient’s data • Maintaining patient’s profiles

2. First step in order entry • Receiving the prescription. According to federal law, a prescription may be transmitted to the pharmacy in the following ways (controlled substances may differ and state laws also apply) • Written • Telephoned • Faxed • Electronically, e-prescribing • Step 2 • Obtain patient and prescriber information • Patient information includes full name, address, contact, date of birth, any drug and food allergies, medical history • Prescriber’s information • Name and address with contact • DEA (required for controlls) • NPI (required for most insurances) • Registration/license (required by some insurances)

3. Step 3 • Data input into electronic patient profile • Name, address and other demographic data • DOB • Medical history • Drug allergy information and Food • Prior Medication/OTC/Herbal use • Drug selection • NDC of the drug chosen must match the one entered into the computer • Determining if a generic can be used • Keying in direction data • Entering refills • DAW codes

4. DAW Codes • DAW codes are used by insurances companies to help determine the reimbursement to the pharmacy and if the medication is eligible for full or partial coverage • These codes are universal and used by all pharmacies and insurance companies • Codes are not required to be memorized for the exam but know the following • DAW=0 means no DAW is indicated (generic ok) • DAW=1 means prescriber indicates brand drug to be dispensed • DAW= 5 means Pharmacy dispenses the brand but realizes it may be reimbursed at the generic rate • DAW= 7 means Federal Law mandates Brand drug

5. Step 4 • Submitting the prescription claim to the insurance company for payment. This online claim processing is called adjudication • Step 5: Generating the label • Federal pharmacy Law (FDCA of 1938) requires the following on all retail prescription labels affix to the container • Pharmacy full information, including telephone • Patient, prescriber, and drug name (state) • Strength of the medication • Direction for use • Quantity dispensed • Date prescription was filled or refill • Rx number • Initials of the RPH • Cautionary statement, if needed.

6. Step 6 • Select the container of dispensing. Most drugs are light sensitive and their dispensing in amber colored containers are required • Vials for capsules and tablets • “Ovals” are wide mouthed containers for compounded creams and ointments • Glass or plastic amber bottles for liquid medications • Some drugs require the original manufacturer labeled container to be dispensed. A very important one (hint: it may be on the PTCE) is Pradaxa ® (Dabigatran) is a anticoagulant used in place of warfarin for many condition. FDA in 2011 requires that the pharmacist dispense drug in the original container and the bottle be dated 60 days after opening • Step 7 • Pharmacist check. Labeled container with the pulled bulk medication and the original prescription

7. Step 8: Dispensing to patient • For all new patients to your pharmacy it is important to give them a copy of the HIPPA notice of privacy practices and to document that the patient received it; same holds true for doctor’s office • As per OBRA 90 requires, the pharmacist must offer counseling • Use of teaching sheets that provide preset information in layman’s term of the medication • Some medications require a patient package insert or PPI to be dispensed with the prescription as per Federal law. These medication classes include: • Oral contraceptives (birth control) • Estrogen and progesterone products (menopausal products) • Isotretinoin (Accutane) • Metered dose Inhalers • PPI are laymen terms for what is contained in the Package Insert • All dispensed prescriptions must comply with the poison prevention packaging act of 1970 • Child resistant caps on all dispensed vials • Except when patient (blanket authorization) or prescriber (single prescriptions at a time) requests non resistant caps (i.e EZ caps) • Exception drugs (i.e Sublingual Nitroglycerin, oral doses of isosorbide, some erythromycin products)

8. Medicare Modernization Act of 2003 established the MTM, Medication therapy management • Intent was to reduce health care costs due to poor use of medication by patients • Pharmacists to help discover these problems and fix them • Allows for billing of insurance for these services by submitting CPT codes • Knowledge of CPT codes is becoming more important in the pharmacy due to increase reimbursements to pharmacists.

9. Institutional Fill Process • Hospitals, nursing homes, LTCF, etc follow the same procedures with some differences: • Ambulatory (out patient prescriptions) are not filled • Patient’s data is not collected but is available on the electronic patient’s profile • Patient’s name, demographics, height, weight, address, DOB • Patient’s insurance information • Patient’s Diagnosis • Patient’s allergies • Patient’s laboratory data • Admission date • Admitting physician • MAR • Medication reconciliation record • Dispensing to the patient directly is not done. Medication are administered by an RN

10. The Joint Commission requires a review of the patient’s home medications upon admission to the hospital. • In addition to this, each time a patient is transferred between units a review of the medications the patient was on must be documented by the transferring physician • This is called Medication Reconciliation • Pharmacist should review this if there are any issue with the patient’s medications

11. Dispensing to the patient’s nursing unit: • Hand delivery to the unit by the pharmacy technician from a centralized pharmacy • Technicians deliver unit dose medications to a ADC (automated dispensing cabinet). The medication is accessible to the RN from the cabinet after the medication is profiled by the pharmacist. • Support a decentralized pharmacy system with specialty satellite pharmacies (cardiac ICU unit would stock cardiac medications in their ADC) • supports with turn around time • Supports pharmacy antidiversion efforts • Omnicell and Pyxis Medistation are the industry standards

12. Pneumatic Air Tube System • Consists of a tunnel system constructed in the walls under a powerful vacuum system • A docking station is loaded with the medication in a special canister • A code is selected that “tells” the system where to sent the canister. • Similar to the system you see at a bank • Drugs that should not be sent this way: • Chemotherapy agents and other hazardous agents • Controlled substances • Drugs that should not be shaken • Glass containers • Flammable agents