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Health

Mail-Order Prescriptions: Usage Date Errors Cause Misery and Increased Costs

Hazardous for you! Many opportunities for miscommunication. Your responsibilities the pharmacy responsibilities, and a call for government action!

You take a long-expired pill and look into the mirror the next morning to see blue hives on your face. You take another expired drug and later go into convulsions.

One is your dumb fault
The other was caused by “the system”

The insurance company compels the patient to use the mail-order drug company for maintenance drugs. The company ships a three-month supply. The patient pays a two-month copay, thus saving a one month cost.

Simple and efficient when it works.

It’s terrible for the patient when it doesn’t. There’s a lot of confusion, finger-pointing, and refusal to fix problems.

Drug expiration dates

Based on past experience, we know that one insulin quits working three or four days after the 28-day expiration date, sometimes sooner. That sounds like one of the least awful consequences of using drugs after they expire — they just quit working.

However, the failure in this instance can lead to high blood-sugar levels and related problems, such as headaches and blurred vision.

Once, I took some penicillin pills more than three years old, long after the expiration date. The next morning, I woke up covered with blue hives. That’s how I discovered that expiration dates are important.

There are two types of expiration dates.

  1. Expiration-date: a date set when the drug is manufactured. You should start taking the drug before that date. However, some drugs explicitly state that you should stop taking the drug on that date.
  2. Usage-date: a date calculated from the number of days that the drug will be effective after the first dose. It is an unknown date until the patient takes that first dose.

Some articles claim that the dates don’t make any difference. Still, based on our experience in the previous examples, I won’t risk it.

The incident

When we received the insulated drug package from the pharmacy company, one vial of insulin was missing. Mathematically, two vials contain enough for three months, but the box states:

“Discard 28 days after opening”

The insulin has a usage-date in addition to an expiration-date. The expiration-date becomes moot upon opening the vial.

You need three vials for three months, plus one extra vial per year. The obvious conclusion was that the pharmacy company was cutting costs by sending two vials to cover three months. At first, the obvious conclusion seemed wrong!

Hassling with the pharmacy company

First step - check the prescription on their website to make sure that it was submitted correctly. In a recent upgrade, the company removed that feature. A patient can no longer see their own prescriptions!

On to Customer Support. They didn’t know anything and transferred us to a Patient Care Technician to discuss the prescription.

The Patient Care Technician couldn’t discuss the prescription since they were not a licensed medical professional. They could not email a copy of the prescription to the patient, either. They sent a printed copy that arrived about two weeks later. They knew nothing about the web page changes and transferred us to Web Support.

The Web Support person didn’t know why they had changed the website and had no way for the patient to see their prescriptions. They transferred us back to Customer Service.

A different Customer Service representative claimed that the doctor sent a prescription for two vials, not three vials. After almost two hours, their only advice was to contact the doctor.

The doctor

We immediately went to the doctor’s office to get a copy of the prescription. The receptionist could see the prescription on her screen, but could not print it. She said, “The nurse who submitted it was too busy to talk about it now. She will call you before 5:00 pm.

After three hours, we still had nothing

We went to lunch, one hour later than usual.

The doctor’s office called later that afternoon. The result from the doctor’s office (not an RN, but a clerk): the pharmacy made the wrong claim about the Medicare gap, which made no sense. The Medicare gap had nothing to do with the prescription.

The clerk agreed to call the pharmacy and correct the mistake. They entered a new prescription for three vials instead of the dosage amount.

The actual prescription

There is a saying in nursing, “Nothing happened unless it is documented.” Today, a video would probably count as documentation.

For the prescription below, the doctor specified the medication, volume per dose, and frequency. The pharmacy specified 2 vials per the Pharmacy Notes.

Scanned portion of prescription, William Myers, 2019

It’s the doctor’s responsibility to prescribe the medication, volume per dose, and frequency. In this case, Lantus, 14 units, and injected once a day at bedtime.

It’s the pharmacist’s responsibility to convert the volume into the correct dosage, and to provide sufficient quantity to cover the time period, in this case, three months.

Using other medications as an example, one or two pills provide the same dose, depending on the manufacturer. The pharmacist includes the number of tablets per dose on the label.

For injected medications, like Lantus, the pharmacist would need to add extra to cover losses when the patient overfills the syringe, then ejects a small amount to get the exact dosage. Even professionals cannot pull an accurate dose every time, and you should never inject medicine back into the bottle, due to contamination.

The coverup

Richard Nixon did not get into trouble about the Watergate break-in itself. He probably did not know about it when it happened. He got into trouble because of the coverup!

In the same vein, everything would have been fine if the pharmacy had acknowledged the problem and shipped the third vial. Instead, they covered it up by blaming the doctor for their mistake.

Then, when the doctor did the pharmacist’s job and changed the prescription to 3 vials, the pharmacy still refused to ship the third vial, thus costing the patient an extra insurance copay.

Also, pharmacies will not refill a prescription until the drugs from the prior one are almost gone, in this case nearly three months after they filled the prior prescription.

Suppose the volume had been ten instead of fourteen units per day. That would have been one vial. The patient would have gone two months without medication, which could have endangered the patient.

What to do?

You, the patient, must be alert at all times and protect yourself as much as possible.

As for “the system,” you can’t do anything except:

Call for an FDA Audit

I suspect that all mail-order pharmacies have the same problem. So, I am calling for a limited FDA audit of all mail-order pharmacies checking for the following:

  1. Do their computer systems have a method in place to handle Usage-dates?
  2. Does the pharmacy have a policy and procedure in place to find errors and ship additional drugs when an error is found?

If nothing is in place, then the FDA should require the pharmacy companies to:

  • Add Usage-dates to their databases. Identify all medications with Usage-dates.
  • Write an audit program to check their prescriptions filled in the last five years for drugs with Usage-dates that were short the required amount.
  • Issue a refund for medications where the quantity shipped was less than the required amount, even if it would have been the free third month under an insurance agreement. In addition, ship the shortage if filled within three months of the audit.
  • Update their systems and procedures to handle Usage-dates

Finally, insurance companies may intensify the problem by pushing their own rules onto the drug companies. If so, they should review their own computer systems and perhaps be audited by the FDA or other appropriate agency.

Conclusion

I intentionally excluded the name of the pharmacy company from this article since I suspect that the problem is widespread. If the FDA is not auditing for Usage-date issues, they should.

I didn’t address it, but neighborhood pharmacies should be aware of Usage-date drugs and have the proper refill procedures in place.

There probably are not many usage-date drugs, but those that exist should be dispensed and handled properly. Hopefully, this article alerts the right people and they will address the problem.

Finally, no matter what the drug companies and pharmacies do, you need to pay attention to the usage and expiration dates.

Convulsion: A sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles…

William “Bill” Myers, Analyzes all, Programmer, retired. If you learn anything new, find enjoyment, have a new thought, then I’m successful. Photo: 1st article

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