Navigating Retail Pharmacy, Post-COVID Edition
Retail pharmacy explained, for patients, providers, and pharmacy newbies.
Hello and welcome to my navigating retail pharmacy FAQ/explainer! The following is a 2023 update of the post I originally finalized in early 2020, written pre-COVID. I’ve since also had experience with multiple chains and outpatient pharmacies beyond the one that spring-boarded me into writing the original. This revamp is meant to incorporate the additional experience I’ve had, add in a few bits relevant to the pharmacy experience in a post-COVID world, and do some writing overhauls I’ve been putting off for years.
This is super heavily inspired by Scott Alexander’s Guide to Navigating Psychiatric Inpatient Care. I’m aiming to present something very spiritually similar for my domain: retail pharmacy. My goal is to attempt to demystify and demuck some of the messiness inherent to retail pharmacy in the US, to give the general public some transparency for what’s happening behind the counter, and to give you some tools to help us help you.
I will try to provide satisfying explanations where I can and at least give you a “this is how it is, here is some of why” where I can’t. I won’t necessarily have sourced explanations for everything and, while I’m confident this FAQ should serve as a passable practical description of things in the pharmacy world, I also expect there’s details that may not be strictly precise as I’ve put them (or may have better, more complete explanations somewhere else).
The real world is messy, and I can’t guarantee that everything here will make perfect logical sense or won’t be outrageous in some ways, but bear in mind that the goal here is to explain, not to justify or defend. Retail pharmacy is very people-driven and customer service-y, so everything is going to be subject to varying personalities, levels of motivation, and work ethic. There may be a variable amount of deviation from what is presented here at your local pharmacy, and I really can’t stress enough that quality will vary widely by location, staff, and level of corporate support. So, if your pharmacy seems especially good or bad don’t be surprised if the situation is not the same at any other given pharmacy, even within the same chain.
Just about everything here was written with the US in mind, I expect much is different outside the US. I practice in California, so that’s the set of laws I’m going to be most familiar with when it comes to several types of practice issues.
My experience is mostly in chain retail pharmacy, with a little bit of hospital outpatient services, which gives me a lot of perspective on common pharmacy problems as well as how they’re handled in different environments. At chains, the pharmacy staff are somewhat insulated from some business-related pharmacy issues, and so I mostly won’t be able to address many of those insights here.
Lastly, I’ll also say that I believe chain retail practice mutates so rapidly that any pharmacist or technician who hasn’t been behind the counter at one within the last few years doesn’t truly have a clear picture of what it’s actually like there anymore, so in that spirit I should disclose that I’ve more or less successfully been out of the chains for a little over a year, and retail practice completely for around six months. In some ways, reading this back almost 4 years after it was originally written feels surreal, as though it was knowledge gleaned from a dream. Most of this was originally written when I was still in the thick of it and I’m confident is still relevant, but time has passed. If anything, expect things have gotten generally worse.
The FAQ will have three broad sections. The first and largest will deal with patient-focused issues and general pharmacy operation. The second section will be tailored to doctors and other prescribers to provide some practitioner-level insights. The third will be a mostly-for-flavor section aimed at new or prospective pharmacists or those looking in from outside of retail.
I. Patients
Why is retail pharmacy such a bizarre circus?
It's easy to imagine the most straightforward scenario, right? Your doctor decides they want you to take drug X, so they hand you a note saying you need some of drug X that you take over to the pharmacy where they keep all of the drug X and the pharmacy hands you back a bottle of drug X. What's the problem?
Well, there’s quite a few potential problems.
Let’s say you pick up the medication prescribed and that night have a severe allergic reaction that puts you in the hospital. What went wrong (or, more realistically, who do we blame)? Well let's start by looking at the note the doctor gave you to verify if what the pharmacy gave you was what the doctor wanted or if what the doctor wanted was what caused the problem. Actually, first: was the note’s writer allowed to write notes? Was the note sufficiently clear to the pharmacy? We'll probably want to require the pharmacy to hang on to that note just to be safe, but how and for how long and where do they keep it?
Pharmacists are pretty well-educated folks; do you think maybe they could have taken the proper steps to have seen your allergic reaction coming? Did the pharmacy ask if you have a history of allergic reactions to similar medications? Did the pharmacy have records of that allergy and not properly catch it before dispensing? Did the pharmacy catch the error and take the proper steps to prevent it from being dispensed anyways? Perhaps we ought to hold them legally responsible for recognizing when a doctor's entire choice of prescription was inappropriate.
How about the medication itself, how is it packaged? Can't just hand over an unlabeled bottle—pills are kind of tough for the average person to identify by sight. Everything has to be clearly labeled. And what if you forget how to take it? Better put directions on there to be sure. What if you need to contact the pharmacy or can't remember which doctor prescribed this one? And so on. We should probably have laws for all of that too.
Who can pick up for you? The pharmacy should probably be responsible for making sure someone you don't know can't come pick up controlled substances on your behalf. What if you have a sensitive medical condition that you don't want your boss to know about? We should probably require there be steps in place to assure it isn't super easy for him to just ask about it.
Speaking of controlled substances, pharmacies are a critical access throughpoint for narcotics and other drugs that people tend to abuse, so it's probably important that we make sure they're responsible for not allowing dangerous addictive drugs to reach the public without scrutiny. Much much more on this later.
Pharmacy is also the business interface of the entire pharmaceutical industry and there's multiple layers of corporate and regulatory hell infesting much of retail practice that makes most things awkward and frustrating for everyone. Your local chain pharmacy is probably under the strain of a distant corporate overlord that is itself sandwiched between pharmaceutical and health insurance giants. Your local chain pharmacy’s employees are increasingly likely to be overworked, understaffed, and under-supported by their district and regional leadership and held to increasingly abstract measurements of their performance. The front lines of retail have both a high turnover and are considerably less attractive to pharmacy veterans with other options, so you can expect to see an increasingly faster revolving door of fresh grads cycling in, being trained poorly, and burning out. There's a lot of why things are the way they are that is a direct result of strong pressures from multiple layers of corporatization.
There's also some of a little bit of something I'll call “professional feature creep”. Pharmacy, like many professions, has a very weird intraprofessional cultural dichotomy between practicioners and academics. A lot of us closer to the public would very much prefer that our professional organizations and academia be advocating for more resources to do our existing jobs while the professional orgs and academia seem to be convinced that we all secretly want to be family practice doctors and need to be taking on more healthcare responsibilities without squaring away the reimbursement for it. Sometimes this is nice, but it also frequently backfires in unexpected ways. For example: it's hard to argue that pharmacies offering immunizations are not an immense net benefit to society, but it also strains workload, creates another corporate performance metric to be squeezed on, and has allowed other outpatient clinics that would otherwise offer immunizations to cut the service in favor of shuffling people off to the pharmacy.
Frustrated pharmacists love to say the reason it takes so long to get your prescription is because we're making sure it won't kill you, but the reality is that even if we were actively trying to kill you it would still probably take around 2 hours and we’d have to fax your doctor first.
Over all, remember that retail pharmacy practice is a process that's still chiefly governed by humans, with all the good and bad that comes with that. Try to keep in mind that there aren't going to be very many people behind the counter whose genuine motives are to prevent you from getting the medication you need, but your pharmacists, techs, and cashiers are people too and are having their own good or bad days. Many of the pointers and explanations I'm going to provide that sound especially arcane or strict may have local exceptions where you can find employees at your pharmacy that are extra willing to go out of their way to help you—the profession is filled with people eager to help out strangers—but often the deck is stacked against this behavior.
The pharmacy sometimes refuses to take my prescription, refuses to give me my refill, or otherwise won't give me the medication my doctor ordered, what's going on?
This is the most basic problem the average person is going to have with their pharmacy, but the hurdle between you and getting your prescription could be one of many many potential things, varying first by where in the process your prescription got hung up.
The first opportunity to reject a prescription is if it's missing one or more of the required elements. Specifics vary by state but generally on every prescription we want to see:
Patient's name
Patient's date of birth
The prescriber's name, office address, phone, fax, DEA, and NPI numbers printed somewhere on the form
Drug name
Drug strength (e.g. 10mg)
Directions for use (should include amount taken per dose, frequency or number of doses per day, and route of administration)
An explicit or implicit quantity
Whether generic substitution is permitted or if brand name medication is required
Prescriber's signature
Date written
Controlled substance prescriptions, by law, may either hard code these requirements or mandate additional information; for example, in California the patient's address must also be provided—but can be added in by the pharmacy. Sometimes missing information can be filled in later as necessary but sometimes not, California also hard mandates hand-written signatures and dates for non-electronic controlled substance prescriptions.
Since communicating directly with prescribers tends to be problematically time- and attention-consuming, some busy pharmacies may require the patient take hard copies back to their doctor for correction if the mistakes are bad enough; that’s often easier than promising we’ll have time we don’t have to try to manually contact them for you.
If your prescription is refused at drop off, try to get specifics on why if possible and go from there. I say “if possible” because there are rare situations where the pharmacy may strategically not give you specifics. For example, if there is a small but critical error on a controlled substance prescription, they may not tell you in order to keep you from stepping out into the parking lot to correct it yourself. I have definitely seen people try to do this. Please don't.
If a prescription is missing something seemingly minor see if they'll consider taking it anyways, especially if the medication is non-urgent and you're willing to wait while they get in contact with your doctor.
If the medication is a controlled substance, there's an additional host of issues. Again, this will be covered very extensively later on.
If the pharmacy takes in your prescription but you're still having trouble getting it, chances are it's an insurance problem. First, it's possible a particular pharmacy isn't contracted with your insurance. (Why? Insurance providers generally have much more leverage in reimbursement negotiations so if they push things too far the only other real option is to just not sign the contract and accept losing access to those patients.) If it's been too recently since you picked up a similar medication, most insurances won't pay for it since they don’t want to be repeatedly paying for you to stockpile medication. Insurance rejects that I’ve seen that quantify this say 75% based on days’ supply but this probably varies by insurance—it’s generally somewhere in between 70 and 75%, so 22 days into a 30-day supply, for example.
Your insurance may only pay for a particular day supply for most medications, usually either 30 or 90 (it could be restricted to either!), and if your pharmacy's software doesn't correct these automatically they may be stuck until fixed manually. Worker's compensation programs are also a frequent hang-up for drug coverage, since every prescription has to be manually approved by an adjuster every single fill.
It could be that your insurance wants a prior authorization, which means that for whatever reason your insurance really really doesn't want to pay for the prescribed medication but might be willing to if your doctor can talk them into it. Pharmacies have zero control in this situation, but we will usually let the prescriber know a prior authorization is required as a courtesy. This courtesy might go away at any time; in 2018 a family in Massachusetts successfully sued Walgreens after the pharmacy staff told the patient's family that they notified the doctor a PA was required, the doctor never completed the PA, and the patient died having not received the medication. All your doctor theoretically needs from us is the same information we use for your drug coverage right off your insurance card; in my experience doctors’ offices will never be checking their patients' drug coverage and might be unwilling to do anything if the pharmacy isn't providing them that information directly.
It's possible you have a doctor that just doesn't do prior authorizations. It’s possible you have a doctor who doesn’t do prior authorizations because they think giving you a manufacturer coupon is the same thing when it definitely is not. It's possible you have a doctor who theoretically tries to do prior authorizations but whose office staff gets constantly hung up on some critical step. It's possible you have a doctor who doesn't understand that authorizations expire and keep trying to fax the pharmacy expired approvals from several years ago.
But it's also technically possible your pharmacy's staff is lazy, inexperienced, or otherwise awful.
Even if your pharmacy isn't superbad, insurance rejects of all kinds can occur for virtually any random reason and dealing with them can be a bit of an art. There are ancient and arcane override codes that magically work that there is no way for one to possibly learn and would be an eternal mystery but for the One Tech Who’s Been Around For Like 20 Years.
Worse: override codes can change over time. For example, at the start of 2020 OptumRx changed their override codes to process opioid prescriptions for non-opioid naive patients and then didn’t even tell their customer service representatives so we had a solid couple weeks of rejects default-insisting prior authorizations were needlessly required and confused insurance customer service reps assuring us this was not the case without even being able to tell us how to fix their own company’s rejects.
In some cases, there are rejects generated by the pharmacy’s software that behave like insurance rejects and have to be manually overridden; these can range from benign (hey there might be an interaction you'll want to double check here) to infuriating (make sure to ask this patient if they'd like to get their Prevnar13 shot today! this reject is sponsored by Pfizer! this isn’t a joke it actually says this!).
Here is where I'll strongly recommend using your pharmacy's website or app to track your prescriptions. Most of them are really quite good and reliable and can quickly tell you if your prescription has been stalled by an insurance hang-up. Frequently all it takes to fix it is to give us a call and bring it to somebody's attention. If the issue is more complex, and the person you're speaking to is sufficiently experienced, they'll be able to tell you more about what's going on. Be aware that chains are increasingly undervaluing experience.
Efficient pharmacies may store new prescriptions received electronically or by fax if there is no insurance information on file for the patient, which is common if the patient is new to the pharmacy, which gives higher odds that the prescription will never be picked up. Filling prescriptions has both obvious real time costs and hidden and not-insubstantial behind-the-scenes costs; indie pharmacists can tell you lots more about how much actual money is lost in real time just to put prescriptions in the ready bins before they're even sold. Every prescription that is not picked up is net financial loss and time wasted, so deciding which prescriptions not to fill is influenced by priors such as the above. The flip side of this is that corporate loves waiters, and storing new patient prescriptions double dips on metrics because you can fill them relatively quickly while the patient waits after they arrive with their insurance information.
Sometimes the pharmacy may not have the prescribed medication in stock, may not have enough for a full fill, or the medication may be “on back-order” (in other words, not available to purchase from their wholesaler). In the second case your prescription may be partial filled. Partial fill copays are sometimes prorated but sometimes not and may require the whole copay up front—this is something that will vary by insurance but the pharmacy may be able to tell you which is happening by looking at your sales history. Your pharmacy should be clearly letting you know you are receiving a partial fill because if you don’t pick up the remainder it’s subject to the ready shelf-life limits (usually somewhere between 10 to 20 days) and may be returned to stock if not picked up in time. Smart pharmacies will partial fill for only a few days to help you remember to come back for the rest sooner rather than later.
How quickly it takes your pharmacy to get medication in that’s out of stock or partial filled will depend on how often they get deliveries and—very importantly—whether their wholesaler also has the medication available for order. Wholesalers warehouse drugs for sale to individual pharmacies and are theoretically independent from both drug manufacturers and pharmacies—though there are few actual choices; an overwhelming majority of all the pharmacies in the US are serviced by only 3 wholesaler giants. Ideally, wholesalers would stock everything, but this is limited in reality by what pharmacies will actually buy (if there are 8 generic manufacturers and 2 of them sell significantly cheaper than the others the other 6 would only be wasting inventory space), what isn’t suffering supply shortages, and what the wholesaler monopsony hasn’t pushed out of the market.
Some pharmacies won't fill prescriptions for over-the-counter products. Generally, this is an efficiency consideration, but this also is likely to be uncommon because OTC prescriptions contribute to script counts. Most of the time your pharmacy is literally just grabbing the same bottle available to you off the shelf in the store aisles, throwing some of it in an amber vial, and then charging you a markup plus dispensing fee—sometimes you're better off getting a bottle of 120 aspirin from the store for $7 than getting 30 tablets packaged by the pharmacy for the $12 they end up having to charge you. If you do have a pharmacy that doesn't do OTCs, there may be some exceptions where you can convince them to anyways. OTCs are very frequently not covered by insurance, but some may be, stuff like omeprazole (Prilosec), loratadine (Claritin), and fluticasone nasal sprays (Flonase) are common examples for things that are technically OTC but may be covered anyways.
There are some extremely rare cases where a pharmacist can refuse to fill a prescription on moral grounds. This used to generally only come up for stuff like birth control where old laws covering for Catholic objections to contraception are still around, however it’s been wielded most recently and controversially to apply to COVID-adjacent questionable drugs-du-jour like hydroxychloroquine and ivermectin (or, double controversially, vaccines). All of the laws that I'm aware of that cover for moral objections require the refusing pharmacist to directly assist the patient in finding either another pharmacist or another pharmacy to get their prescription filled with, so if this happens to you there is obligatory recourse.
Lastly, and I wish this didn't have to be said but it definitely does, everyone should be aware that you have to actually request a prescription be refilled in some way, and that if your prescription doesn't have refills remaining you aren't going to automatically get more medication. Most pharmacies will notify your prescriber as a courtesy if you have run out of refills, but this may not apply until you've requested refills on something that has none left, so try to stay on top of how much you have remaining—again, strongly recommend using your pharmacy's website or app if available. These requests may be denied by the prescriber and your pharmacy may not notify you by default if this occurs. The most common reason I see for refill denials is prescribers requiring patients to have regular appointments scheduled.
If you're seeing a new doctor, have them send new prescriptions ahead of time or at least let your pharmacy know to request refills from the new provider since it may not be possible or convenient to send refill requests on old prescriptions to a new provider. Prescriptions also have an expiration date and no number of refills remaining is valid if that has passed. This expiration date is generally one year from the written date for normal prescriptions and six months for controlled substances. You will virtually never go wrong if you directly call your prescriber yourself to resolve refill authorization problems, it just about universally speeds up the process if the patient contacts their doctor directly.
My doctor gave me a prescription for a cane/walker/compression socks/bandages/breast pump/adult diapers/etc., can I get these filled at the pharmacy?
Your local pharmacy may sell these items, but for the most part we’re only contracted for reimbursement for medications. Those kinds of non-drug items are all broadly categorized as “medical devices”. For Medicare, these are covered by Part B. There are a few exceptions for pharmacy, typically medication-adjacent hardware such as diabetic testing supplies and nebulizers, but most chain pharmacies don’t stock nebulizers and many pharmacies outside of the chains are less willing to wrangle Medicare Part B to allow it for diabetic supplies (though most non-Medicare drug coverage will cover diabetic supplies).
Prescriptions for things like walkers aren’t worthless though! You’re looking for a medical supply store, which can be set up to bill your insurance for medical devices with a prescription. You can typically find the closest one to you just by Googling “medical supply store” but your local pharmacy may know where the nearest one is because they will have been asked this a billion times.
My pharmacy says they’re trying to contact my doctor but my doctor says they haven’t heard anything from the pharmacy OR my pharmacy was supposed to have received a prescription from my doctor but they say they haven’t received anything, what’s going on?
Missing prescriptions or other things that were supposed to be sent one direction or the other is generally reducible to human error and there’s always going to be some degree to which these sorts of problems are occasionally unavoidable. If it’s a frequent hang-up, best I can tell you is don’t be afraid to look for patterns with regards to who seems to be causing the most trouble and take your business elsewhere.
If a prescription is being held up for clarification try to find out why, if possible, because sometimes you might have the missing information yourself. For example, if the prescription is from a physician with a signature the pharmacy isn’t familiar with and a name isn’t checked off, you’ll probably know which doctor you were seen by, and this may be good enough for most pharmacists coming from the patient (especially if it’s not a controlled substance). If there’s bad handwriting at play and you know how it’s supposed to be written, sometimes a suggestion is all that’s needed to make it make sense.
Many pharmacies and pharmacists may strongly prefer to fax on issues instead of calling, with varying degrees of stubbornness, since communication by phone tends to be kind of risky from a time management perspective. This also applies to doctor’s offices though too and can create some awkward stalemates. General healthcare hasn’t really caught on to email or direct messaging, so fax ends up fitting everyone’s requirements fairly well in most cases. If something is more urgent than a fax will fix, try to politely nudge someone on either side into calling.
Does it really take so long to put pills in a bottle?
Let’s run down the whole basic process from our perspective. First, here’s the best-case scenario:
You drop off your prescription, everything that’s required to be there is there and accurate.
Your prescription is scanned into the system by the pharmacy tech or cashier working the front pharmacy counters.
Your prescription is typed from the scanned image. This may be done by the same person who scanned it in right away if they don’t have another customer immediately in line or may be done by someone else in the pharmacy depending on who has the spare time. Because this is a best-case scenario let’s say the cashier isn’t busy and is super experienced, so she just types it up right away with no errors.
A pharmacist reviews the typed prescription to ensure accuracy compared to the scanned image, checking for appropriate product selection, dates, quantity, directions, day supply, refills, and prescriber selection but also for therapeutic appropriateness, potential interactions with other medications or allergies on file, and controlled substance (or other legal) requirements.
Insurance adjudication occurs hereabouts; since we’re in a dream scenario none of potentially hundreds of problems that can crop up here occur and everything processes fine.
The prescription is then queued to be physically filled by a pharmacy tech. Because we’re experiencing a momentary surge in good fortune the tech doesn’t have to count out something obscene like a 90-day supply of 3 gabapentin capsules taken three times a day, or, if they do, they have counting machines or other automation to do it for them.
The filled product is reviewed one more time for correctness and bagged by a pharmacist, then subsequently placed in the ready bins or carousels by someone.
Now it’s ready to pick up! Since we’re running this simulation with all variables optimized, let's say you’re waiting right there and are able to pick it up immediately and you have all the cash on hand to cover your copay or your card isn’t declined. Everyone is happy.
Now first keep in mind that every one of these steps is occurring simultaneously for any number of 1 to 50 (or more) prescriptions at a time depending on how busy things are at the moment. This also doesn’t include all the other work we’re expected to do additionally throughout the day like all manner of inventory maintenance, recordkeeping, supply ordering, delivery processing, answering phones, adherence calls, and general customer service and management tasks.
I’ll let this DrugMonkey classic describe a less optimistic scenario:
You come to the counter. I am on the phone with a drunk dude who wants the phone number to the grocery store next door. After I instruct him on the virtues of 411, you tell me your doctor was to phone in your prescription to me. Your doctor hasn't, and you're unwilling to wait until he does. Being in a generous mood, I call your doctors office and am put on hold for 5 minutes, then informed that your prescription was phoned in to my competitor on the other side of town. Phoning the competitor, I am immediately put on hold for 5 minutes before speaking to a clerk, who puts me back on hold to wait for the pharmacist. Your prescription is then transferred to me, and now I have to get the 2 phone calls that have been put on hold while this was being done. Now I return to the counter to ask if we've ever filled prescriptions for you before. For some reason, you think that "for you" means "for your cousin" and you answer my question with a "yes", whereupon I go the computer and see you are not on file.
The phone rings.
You have left to do something very important, such as browse through the monster truck magazines, and do not hear the three PA announcements requesting that you return to the pharmacy. You return eventually, expecting to pick up the finished prescription...
The phone rings.
...only to find out that I need to ask your address, phone number, date of birth, if you have any allergies and insurance coverage. You tell me you're allergic to codeine. Since the prescription is for Vicodin I ask you what exactly codeine did to you when you took it. You say it made your stomach hurt and I roll my eyes and write down "no known allergies". You tell me...
The phone rings.
...you have insurance and spend the next 5 minutes looking for your card. You give up and expect me to be able to file your claim anyway. I call my competitor and am immediately put on hold. Upon reaching a human, I ask them what insurance they have on file for you. I get the information and file your claim, which is rejected because you changed jobs 6 months ago. A dingus barges his way to the counter to ask where the bread is.
The phone rings.
I inform you that the insurance the other pharmacy has on file for you isn't working. You produce a card in under 10 seconds that you seemed to be unable to find before. What you were really doing was hoping your old insurance would still work because it had a lower copay. Your new card prominently displays the logo of Nebraska Blue Cross, and although Nebraska Blue cross does in fact handle millions of prescription claims every day, for the group you belong to, the claim should go to a company called Caremark, whose logo is nowhere on the card.
The phone rings.
A lady comes to the counter wanting to know why the cherry flavored antacid works better than the lemon cream flavored antacid. What probably happened is that she had a milder case of heartburn when she took the cherry flavored brand, as they both use the exact same ingredient in the same strength. She will not be satisfied though until I confirm her belief that the cherry flavored brand is the superior product. I file your claim with Caremark, who rejects it because you had a 30 day supply of Vicodin filled 15 days ago at another pharmacy. You swear to me on your mother's...
The phone rings.
...life that you did not have a Vicodin prescription filled recently. I call Caremark and am immediately placed on hold. The most beautiful woman on the planet walks buy and notices not a thing. She has never talked to a pharmacist and never will. Upon reaching a human at Caremark, I am informed that the Vicodin prescription was indeed filled at another of my competitors. When I tell you this, you say you got hydrocodone there, not Vicodin. Another little part of me dies.
The phone rings.
It turns out that a few days after your doctor wrote your last prescription, he told you to take it more frequently, meaning that what Caremark thought was a 30-day supply is indeed a 15 day supply with the new instructions. I call your doctor's office to confirm this and am immediately placed on hold. I call Caremark to get an override and am immediately placed on hold. My laser printer has a paper jam. It's time for my tech to go to lunch. Caremark issues the override and your claim goes though. Your insurance saves you 85 cents off the regular price of the prescription.
The phone rings.
At the cash register you sign...
The phone rings.
...the acknowledgement that you received a copy of my HIPAA policy and that I offered the required OBRA counseling for new prescriptions. You remark that you're glad that your last pharmacist told you you shouldn't take over the counter Tylenol along with the Vicodin, and that the acetaminophen you're taking instead seems to be working pretty well. I break the news to you that Tylenol is simply a brand name for acetaminophen and you don't believe me. You fumble around for 2 minutes looking for your checkbook and spend another 2 minutes making out a check for four dollars and sixty seven cents. You ask why the tablets look different than those you got at the other pharmacy. I explain that they are from a different manufacturer. Tomorrow you'll be back to tell me they don't work as well.
Now imagine this wasn't you at all, but the person who dropped off their prescription three people ahead of you, and you'll start to have an idea why...your prescription takes so damn long to fill.
And again, this is happening simultaneously for any number of 1 to 50 (or more) prescriptions at a time. If you look at the ideal scenario again, anything going awry at any step there can add minutes to days for each individual issue with each prescription and worse—chasing down problems can add time to every other prescription being worked on. This is how I would explain why I personally prefer faxing to direct phone calls in most situations; if I have 5 people in my waiting room and 50 prescriptions in my queue, getting stuck on hold for even a few minutes can have a compound effect on workflow.
Can a prescription be filled in less than 5 minutes? Sure, if everything is quiet and the stars have properly aligned. Is it a reasonable expectation in most situations? Probably not.
Should I wait or come back later? How do I know when my prescription is ready?
If you wouldn’t have time for a regular doctor’s office visit, anticipate not having enough time for a trip to the pharmacy if your prescription is not already ready. That said, if you have anywhere from 5-30 minutes to kill and don’t mind hanging around, chains love waiters. This makes sense generally from the pharmacy’s perspective; for one, it’s easier to want to be putting people in your lobby before people chilling at home, but it’s also a win for the pharmacy because very few prescriptions that someone is willing to wait in the lobby for go unsold.
Chain upper management gets really weird about waiters, insisting that people love to come into the pharmacy specifically to wait while you fill their prescription. My intuition is that basically nobody prefers this over having their prescription ready ahead of time. If you dig and kind of call them out on it, they'll eventually admit it's to prevent ready prescriptions from being returned to stock. (Why don't we leave prescriptions ready forever? See the next question below.) Chain pharmacies will usually have policies that incentivize trying to get people to wait for their prescriptions and policies that directly encourage us to treat waiters preferentially. If you want to get your prescription the fastest from any stage of the process to ready, waiting for it at the pharmacy is the surest way for it to happen. Note, however, that this does not include the drive thru! Drive thru should be used for drop off and pick up only.
“Should I wait” is a question that obviously depends on your situation. If you’re already at the store you can kind of gauge potential wait times by how busy things look; if the waiting room is full, there’s a long line, and there’s only one pharmacist on duty chances are you might have to sit tight for quite a while if you want your flu shot right then.
I would encourage putting in refills well in advance of needing them, in which case it’s hardly necessary to hang out at the pharmacy until they’re ready. Using your pharmacy’s website or app will likely be the best way to know from a distance if your prescription is ready, or why it’s not ready if that’s the case. The next best option is to call your pharmacy and ask, but this is broadly inconvenient for everyone (and I wouldn’t recommend making it a habit) or relying on automated alerts, which can help but can also get kind of out of control and annoying pretty easily—if they even work correctly.
I received a call that my prescription was ready but when I get to the pharmacy there’s nothing to pick up, what’s going on?
Speaking of automated alerts going awry, fun fact: a few of the major chains use automated refill reminders that begin “your prescription is ready to be refilled”. These cause constant headaches because there are an awful lot of people who tend to only hear the first four words. It’s disturbingly common for us to see people get any kind of alert and jump right to the conclusion that they have a prescription to pick up. If in doubt, call and talk to a person—that way if they still tell you something is ready and it’s not there when you arrive you have someone you can blame. For absent prescriptions, most of the time there’s not anything deliberately nefarious going on and there are a couple common culprits. For instance, if you use multiple pharmacies in the same chain there’s a clear chance for confusion here.
This was alluded to previously, but prescriptions have a time limit for how long they can be ready. Reimbursement for prescriptions take the form of claims filed through your insurance for the retail cost of the medication. That claim is a hold on money and can’t be permanent so the law prohibits how long a prescription claim can be active. Pharmacies deal with this by having policies that cover how long a prescription can be ready before the package needs to be deconstructed, medication returned to stock, and the insurance claim reversed. This time period is usually somewhere around 10 to 14 days and generally also applies to all prescriptions regardless of insurance processing. Please don’t be surprised if that prescription your doctor sent over in February isn’t still ready on the shelves in July.
Returning ready medication to stock is both a massive, wasted overhead cost and a significant part of a pharmacy technician’s daily duties, so pharmacies are highly incentivized to get you to actually pick up what they have spent resources making ready. Alerts for this may be automated, but typically your pharmacy’s staff are supposed to be persistent in letting you know that there’s something they have ready for you that they really want you to come pick up if it’s about to be put back (however these and other outreach calls are time- and labor-consuming and an easy thing to drop if your pharmacy is too busy). If you’re just receiving return-to-stock warnings but still take a few days to get to the pharmacy at this point, it may have already been put back.
I need my prescription ASAP for real, is there anything I can do to get it bumped up?
As described above, the simplest way to get your prescription filled the quickest—and the way generally supported by corporate policies and pharmacy staff sensibilities—is to be in the waiting room. Again, not the drive thru! If you’re not able to be present, you can certainly try to remotely request things be moved up but don’t be surprised if the pharmacy’s workflow won’t really accommodate it. Keep in mind your pharmacy will be working through several hundred prescriptions in a day, so if everyone starts requesting everything be filled right this instant you’ll be right back to square one pretty quickly.
Why does the pharmacy I go to always seem to be understaffed?
It’s been true in pharmacy for a long time now that per prescription reimbursement is in kind of a dismal state and that the most straightforward way to deal with this was by sheer volume. It’s sort of up for debate whether pharmacy on its own is a failing business model (I also think it’s maybe an open question whether chain pharmacy corporations even want to be running pharmacies at all any more) and we could speculate on whether or not chain pharmacies are running out of other things to cut to stay open, but the reality is that the recent trend has been to cut staffing.
A few years ago I would have assumed this problem was unique to pharmacy but it’s starting to seem as though there are frequent viral examples suggesting that most corporate retail operations broadly are suffering from a mix of aggressive understaffing and employees unwilling to tolerate poor working conditions. I don’t really know why this is so trendy with upper management at so many companies where service quality is presumably important.
It continues to be alarming that, even if pharmacy isn’t exactly a blue-collar job, things are getting to where old school labor issues like insufficient breaks, staff coverage, and working conditions are becoming very real, stressful problems. Most states still don’t have lunch break requirements, and it’s extremely possible your beleaguered pharmacist is going through every shift without being given a minute to eat anything. It used to traditionally be that we needed laws to restrict the maximum number of pharmacy technicians that could be working per pharmacist, now we’re starting to need laws requiring the pharmacist to have any help at all.
Do you have control over prices? Why is the price for my medication different from last time? Why do I pay so much for insurance and yet they pay so little of my costs at the pharmacy?
We in the chain store definitely do not have control over prices, and what control our company has is all in some corporate office way far removed from us that we don’t have access to. If your copay has suddenly changed, that's generally not us, that’s a question for your insurance. When the copay changes the price we’re charging hasn’t changed, what’s different is the share of it that your insurance is willing to pay. Insurance formularies can change at any time with no notice to anybody and thus copays can change very abruptly, and drugs that didn’t require a prior authorization before might suddenly require one now. Your insurance provider will always be able to tell you more than we can when it comes to changing copays.
The last of the above questions is a little more complicated, so let’s do a quick rundown of insurance as it relates to drug coverage and us at the pharmacy. But first some terminology:
Premiums - Premiums are the “subscription fee” that you’re paying monthly to be covered by your health insurer’s plan. If you’re getting health insurance through your employer this is typically being deducted from your paychecks.
Deductible - Your deductible is a chunk of money that you have to work through mostly yourself in order for your full coverage to begin. This naturally sounds really absurd that you would pay for your insurance to do nothing to help you at first but the quick and dirty why is that deductibles are theoretically what keeps premiums low enough to make health insurance palatable to enough people to exist at all. This doesn’t mean your insurance is automatically paying nothing—you may still have very low copays for lower tier medications—but it does mean you should expect there to be a lag before your insurance coverage ramps up. You should also notice that differences in premiums and deductibles are often what separates the minutiae of several plans aside from coverage specifics; plans with low premiums will generally have higher deductibles and vice versa—more on this later. Plans typically cycle yearly, and deductibles usually reset on January 1st.
Copay - Your copay is what’s left over after we’ve charged your insurance for your medication. If the retail price of your prescription is $100, we send the bill to your insurance provider while we fill your prescription and they send it back to us telling us how much they’ll pay if you pick up the medication. If they tell us they’ll pay $95, the remaining $5 is the copay you pay at the register for us to hand you the medication.
Formulary - A drug formulary is the list of medications your health insurer is willing to pay for. Usually this is separated into tiers; tier 1 usually includes most generic medications, tier 2 includes “preferred” brand name medications, and tier 3 includes other covered brand name medications. Copays are often decided by tier, with higher copays for higher tiers. In theory this is to encourage prescribers to prefer cheaper medications but may also be influenced by various types of behind-the-scenes kickbacks too. In my experience drug formularies are rarely being taken into account by prescribers since doctors don’t really have the time or resources to adapt their prescribing habits to each individual patient’s insurance’s drug formulary (though they’re technically all publicly available). For any drugs not on the formulary, your health insurance may be persuaded to pay for them via a prior authorization.
Prior authorization - When a medication is not on your insurance’s formulary, they may be willing to cover it if your prescriber requests a prior authorization. In most situations, your insurance is looking for medical justification for why your prescriber wants a particular medication as opposed to other (ideally cheaper or theoretically more effective) options that are available. As described previously, this is between your doctor and your health insurance, it’s completely out of our hands at the pharmacy. Prior authorizations are not guaranteed and can be denied, and an approved prior auth doesn’t guarantee no or low copays.
Coverage gap/donut hole - This only applies to Medicare; basic Medicare coverage has an upper limit for how much they’ll pay for drug coverage before you hit what’s referred to as the coverage gap (or, colloquially, the donut hole). Inside the coverage gap, Medicare is covering virtually no amount of the drug cost, however the coverage gap itself has an upper limit beyond which coverage will kick in again. If you have a solid grasp of what a deductible is you can think of the coverage gap as a second deductible. Beyond the far side of the coverage gap you reach what is referred to as catastrophic coverage, where drug coverage returns extensively with very tiny or nonexistent copays.
Most people in the US have drug coverage through their work, through Medicare, or through state Medicaid programs but even if you don’t the structure is still mostly the same. The insurer you sign up with manages everything regarding your healthcare overall, but typically they contract out benefits related to drug coverage through a pharmacy benefits manager (PBM), since drug coverage is its own giant nightmare of a problem separate from other healthcare. As with many things in the pharmacy world PBMs are fairly heavily consolidated (Express Scripts, Caremark, and OptumRx make up 78% of the PBM market) and PBM misbehavior is a very large issue in the pharmacy world that is generally absent from the public consciousness. We at the pharmacy are interfacing with your health insurance through their PBM, and your PBM is generally who is deciding your insurer’s drug formulary and ultimately sets your copay.
So why do you pay so much for insurance yet they pay so little at the pharmacy? Well first, are they really paying so little? Most pharmacies will tell you somewhere on the dispensed information leaflet how much your insurance has saved you; it’s not terribly uncommon to see a $200 copay for an $8000 medication. Else, if you still have a deductible or are in the coverage gap, those may explain high copays at the pharmacy. If your insurance doesn’t want to pay for a drug that’s not on its formulary and your doctor can’t or won’t do a prior authorization or change it to something on the formulary, chances are your out of pocket cost is going to be astronomically high. Drugs in general being monstrously priced to begin with is part of a larger issue of cost disease in medicine.
Can you (or my local pharmacist) help me choose an insurance plan?
Giant extra I-am-a-pharmacist-but-not-yours type disclaimer here: the following is super broad advice and is not meant to replace talking to someone with expertise and access to information to assist in choosing the right insurance plan for you.
While the pharmacist in store may not be well-equipped to help you, every chain has an entire department they can refer you to that will help you out for them. Independent pharmacies may be more flexible in helping you directly. Choosing a plan isn’t necessarily complicated, especially if you’re armed with a clear understanding of the terminology outlined above. The most basic things to look for as far as drug coverage is concerned include looking for plans that have every medication you’re taking on their formulary (or have clear alternatives) at as low of a tier as possible, plans that prefer your favorite pharmacy for lower copays (if you prefer not to switch), and plans that have favorable premiums and deductibles. These shouldn’t be the only considerations—for example you’ll also want to make sure your favorite doctors are in-network for your insurance. Insurance providers do a pretty okay job of giving you most of the information you need and usually have tools to help you pin down what drugs (or providers) are on formulary (and in network respectively). You might have to dig a little to find what pharmacies a plan prefers, whether they’ll be trying to pressure you into using their mail order pharmacy, and whether they have a strong preference for or against 90 day supplies.
Since plans with larger deductibles will often have lower premiums, you can try to minmax how much you spend in the year by picking based on what you expect for the coming year. If information from previous years is available, look at how far you’ve historically made it through your deductible. If you normally don’t finish your deductible you may want to prefer a plan with a lower premium/higher deductible; since costs through the deductible will be stable you’re thus saving money with lower premiums if you’re expecting to not make it through the entire deductible. If you’ve been clearing your deductible in past years, that’s a sign that you may want a low deductible/high premium plan; you’ll be paying more each month in premiums but if you expect to be burning through your entire deductible, full coverage will kick in sooner meaning more of your drug costs will be picked up by insurance and may be a net savings even with the higher premiums. If none of that information is available to you, you’ll have to try to guess what you’ll need in the coming year.
The other thing to keep in mind is that enrollment periods for insurance plans are often limited to specific times of year. If you get insurance through your employer this period may vary, but it often lines up with Medicare open enrollment which is generally October 15 through December 7. Open enrollment is generally the only period during which a particular plan carrier can be chosen or changed, barring rare exceptions. (Does anyone else think it’s weird and horrifying that you’re locked into health insurance plans for an entire year with only a 53 day window to choose?)
Is there any downside to using discount cards?
Discount or coupon cards are a great way to cut costs at the pharmacy and come in a couple different flavors, but aren’t without caveats.
The first most straightforward issue is that a majority of them—by law—don’t work for people covered by federal and state government-funded plans. This chiefly means Medicare but also includes Medicaid, VA, military, and state/federal employee plans. Supposedly this is because all of those plans are already receiving discounts off the manufacturer price but it doesn’t tend to be much solace for the person at the far end who’s still stuck paying $300 copays for $700 medication.
If you’re on a private commercial plan, manufacturer discounts are your best friend for high tier or non-covered medications. Manufacturer coupons operate like rebates by giving your insurance or pharmacy a little bit of their money back in exchange for playing along with their (usually-not-covered-well-by-insurance) drugs. There aren’t very many major drawbacks to using them that I’m aware of and they can pretty ruthlessly cut down copays. They can be tricky to get to operate correctly, since some may need to be billed to a primary insurance before the discount will properly kick in and these kinds of billing shenanigans can take some experience to get right consistently. Do be aware that if a coupon card operates without insurance, it won’t be contributing to your deductible. Manufacturer discounts are generally exclusive to private plans but a few rare ones do exist that play nice with Medicare so it may still be worthwhile to look into but always be sure to carefully read the fine print.
Manufacturer discounts are usually available on their website. Often you can just Google “[drug] manufacturer coupon” and find your way there. There may be some form of signing-up-to-be-advertised-at involved and come with the same vague privacy warnings I’m about to give below for other discount cards. There may be limits on how much medication they’ll discount, but sometimes those arbitrary limits can be overcome by simply signing up for it again. Your doctor may have discount cards on hand to give you for stuff they like to prescribe because drug reps tend to hand them out like candy along with the literal candy.
The other common flavor of discount cards are general use third party discount cards, most famously GoodRx but also stuff like FamilyWize, SingleCare, Prescription Solutions, et al. Third party discount cards end up being really bad for us for murky, confusing behind-the-scenes reasons I won’t get into here. They’re also pretty notorious for harvesting personal data, both the information you use signing up for their service and the data your pharmacy has to transmit to them for adjudication. You might want to wonder how these companies are able to afford celebrities for their TV commercials. They also don’t typically work with insurance, but if you’re okay with all of the above they can skim a bit off the out-of-pocket price.
I have a specific request or need regarding one or more of my medications, is there anything I can do to guarantee things will be done how I need?
Communication is key, but honestly I recommend not trusting your pharmacy and making double extra sure everything is how you need it before you leave the store. If you prefer a particular manufacturer or need something packaged a certain way do not leave the store without verifying you got what you wanted because sympathy tends to be lower the longer you wait and the angrier you are about bringing it to someone’s attention. You don’t need to be hostile about it, but you’ll always be safe if you are expecting that a specific need won’t be addressed unless you’re bugging someone about it at the register every time.
Tracking specific requests can get tricky in a busy pharmacy and expecting things to magically work out and being upset when they don’t only encourages pharmacy staff to move towards just not accepting special requests at all. The better-staffed your pharmacy is the easier it is to handle special requests and if it’s something that is essential to you, consider looking for a local indie pharmacy if available since offering more personal, customized service is often their competitive edge.
Sometimes when I pick up a prescription the cashier forces me to talk to the pharmacist before they hand the medication over, what's going on?
Mandatory patient counseling requirements are a result of the federal Omnibus Budget Reconciliation Act of 1990. One of the provisions therein directed states to implement laws requiring pharmacists to offer medication consultation at dispensing to any federally funded Medicaid patients. A few states did just that bare minimum. Several (including both states where I’m licensed) took that idea and ran with it, instead deciding to require this to apply to all patients receiving any new prescriptions at all. Individual pharmacists may vary in their zeal to live up to this requirement, but the rough takeaway is that if you have a question about your medication the pharmacist may be legally compelled to answer it.
[Trigger warning: a few paragraphs of professionally controversial editorializing] Counseling requirements aren’t exactly a hill I’m prepared to die on, but I’m not personally convinced they are either automatically a good idea or something that people generally want. What I’m not saying here is that pharmacists should be cloistered from the public; having direct public access to a health professional is unambiguously good, but it's also telling that around half the questions I get are "do you guys have a bathroom?"
What I am saying is, look, how many people are even aware that mandatory counseling is a thing and are aware or upset if they’re not getting it? Inasmuch as patient education is a problem, its optimal solutions are probably more varied and personalized than your pharmacist giving you a drug monograph exposition dump, plus or minus the recommended open-question quiz afterwards.
But I’ve caught numerous prescribing errors by counseling patients on new medication at pickup, are you an idiot?
Okay first off, wow rude. Second, go away, this FAQ section is for patients.
If the hypothetical pharmacist I’m now arguing with is catching mistakes by doing to-the-letter OBRA ’90 counseling, that’s great, again I’m not going to say you shouldn’t (or that I don’t). But A) if you’re catching a lot of mistakes like this maybe we ought to be asking some bigger questions and B) you’d probably be surprised/horrified how often people aren’t being asked open ended questions every time they pick up new medications and yet are not dropping dead.
My chief objection to prescription counseling mandates is how context insensitive it is, both to patients and to your average retail pharmacist who is being buried under increasingly impossible workloads. There are a lot of people who are going to be well- or best-served by the bog-standard, “Do you have any questions about your medication?” And the people’s whose lives are going to be most impacted by your input as a pharmacist are the ones who answer “yes” to that question: parents with sick children who want to be sure how to give their augmentin, new diabetics who have suddenly had their world turned upside-down and need to know how to use a glucometer, the patient who is lost after their doctor threw a bunch of new medications at them but didn’t have the time to explain why or what they are, etc. I’ve seen all of those, and multiple times each.
Everyone probably should be counseled on their medication (hint: maybe not by the person answering two phones and desperately trying to get some dude out of their drive-thru), but not everyone needs to be, and all I’m saying here is that I sort of feel like that’s not an unimportant distinction.
I am or someone I know is on controlled substances for genuine reasons but my pharmacy is really strict about fill dates etc., is there anything I can do to make it less of a headache?
Controlled substances come with a whole bunch of problems that make them especially uncomfortable for everyone. Why? The short version is that the DEA expects every pharmacist to firmly enforce the Controlled Substance Act while refusing to provide concrete guidelines for what constitutes violations of the law, under threat of prosecution, fines, and license revocation, creating an environment where filling any controlled substance is a vocational and financial risk with little measurable benefit over other types of prescriptions.
The long version is...well, to start, here's 21 C.F.R. 1306.04(a):
A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription within the meaning and intent of section 309 of the Act (21 U.S.C. 829) and the person knowingly filling such a purported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the provisions of law relating to controlled substances.
This is what's being referred to when someone in pharmacy invokes "corresponding responsibility" and is why pharmacists are strictly bound to enforcing the Controlled Substance Act. Every sentence there has broad definitional problems, especially with “acting in the usual course of his professional practice” and “the usual course of professional treatment" being unfortunately vague.
The DEA advises us to watch for "red flags"—signs that a patient may not be obtaining a prescription for legitimate use—but doesn't bother to codify any of it and doesn't even provide an official list of red flags. The lines between poorly-written-but-legitimate and correctly-written-but-not-legitimate blur very badly. Some frequently cited red flags include:
Prescriptions for large quantities of drugs, especially in combinations, and double especially if that combination is opioids, benzodiazepines, and muscle relaxants
Frequent prescriptions from the same prescriber for multiple patients with similar details (directions, quantities, etc.)
Multiple identical prescriptions for people at the same address
Unusually long distances between addresses for the patient, prescriber, and pharmacy
Patients paying in cash or refusing to use insurance
All manner of suspicious incidental behavior
You might notice a frustrating pattern here: these all have plausible exceptions. It’s not actually that unusual for someone to have all of pain, anxiety, and muscle problems; someone might have unpredictable severe muscle spasms that cause severe pain and thus makes them incredibly anxious. Couples coming in with identical prescriptions strikes me less as automatic abuse and generally points to prescribers having stubbornly consistent/lazy prescribing habits. Sometimes someone needs a specialist and the nearest psychiatrist/pain specialist/specialty surgeon is 300 miles away. Sometimes people just flat don't have insurance.
The awkward/more sinister flip side to this is that, since the law directs us to refuse any prescription we think may possibly not be legitimate (without providing ironclad guidelines for that decision process) we can reject any controlled substance prescription for just about any reason as long as we have even the flimsiest justification for why it may not be legitimate. Since there's no proper listing of red flags, just about anything can be stretched to qualify.
Chain pharmacy side note: in chain pharmacies, script counts omit controlled substances. Supposedly this is to prevent pill mills—pharmacies that deliberately mass fill controlled substances (for some reason every time I’ve heard this discussed everyone blames Florida for ruining it for everyone). Script counts are the average number of prescriptions a pharmacy processes in a day or week, depending on what time frame is being discussed. For most stores this average is somewhere between 100-500 per day, with the lower end being stores that are pretty dead and the upper end being an average busy pharmacy. If you ever happen to hear about your pharmacy's script count, it may be leaving out controlled substances, which can be a very substantial amount—my first store’s controlled substance volume was around 10-15% of our total daily volume. Those metrics were showing with and without controlled substances, so this isn’t really even some super secret thing. I've been told labor hour allotments are based partly on script counts that don't include controlled substances (this is admittedly difficult to verify because corporate refuses to be transparent about this), so it’s very possible this is contributing to understaffing since we're not being staffed for our true script count. This adds to the idea that, not only is every controlled substance we fill a legal liability in theory, it creates a soft incentive to get anyone filling only controlled substances to take them somewhere else to save on labor time.
What can you do about getting controlled substances filled being a major headache? A lot that more or less boils down to making yourself and your prescription look as not-suspicious as possible. If you're on narcotics or anxiety medication long term, try to get referred to a pain management specialist or psychiatrist respectively instead of getting them from a family practitioner. There are a few local pain specialists who are frankly stricter than I am that I generally trust to do a lot of my workup for me and I'm happy to recommend them. It might help to know which prescribers your local pharmacists trust more.
If you have a regular pharmacy, do your best to stick to it. If you don't have a regular pharmacy, be prepared to have to look around quite a bit for that ER script, especially if your local ER is known to be pretty sketchy and is giving out oxycodone to everyone who comes in with a headache. Be up front if you're getting multiple controlled substances from multiple pharmacies and multiple doctors for real reasons. Don't assume we can't see what you're getting at other pharmacies and from other doctors; Missouri was the last state to get a state-run prescription drug monitoring program for controlled substances in 2021. A nationwide program is probably not very far off.
Having done something for you once or multiple times in the past is no guarantee that there won’t be an issue with it this time. If you get shorted, be as honest and non-confrontational about it as possible. Expect that vigorous arguing will only ramp up suspicion, so I would suggest trying to avoid it unless you can provide immediate proof of some claim. If you lose medication or it gets stolen, get a police report and bring that. Documentation of anything in general is helpful, especially information related to why you need a particular dose of a particular medication. Be nice to my techs.
Never make threats, they won't work and are the mother of all red flags. Don't threaten to complain to corporate when controlled substances are involved because it's one of the few complaints they can’t overreact to (and veteran pharmacists will be very aware of this). Don't joke around and please don't tell me that you gave your mom some of your methadone for her headaches. Be nice to my techs.
Every pharmacy may have different local rules for controlled substances regarding pickup dates or other details such as whether you can wait for them on the same day. In my opinion it's fair to expect them to be able to tell you what those rules are and for them to follow them consistently but they may not be strictly written down anywhere, there may be new employees or floaters that don't know the local rules yet, and those rules can change over time.
Pickup dates are generally from the date sold, which may not be the same as any of the dates on the bottle; if the medication sits ready for a week the fill dates on the bottle don’t magically update. I tell people to hang on to their receipt for the date on that. Some pharmacies will only fill with insurance or won’t fill prescriptions that require prior authorizations as cash pay since insurance claims help reduce the ability to fill the same medication at multiple pharmacies. Some pharmacies may take cash but won't accept discount cards to discourage or make it less palatable to sell prescriptions on the street. Pharmacies that are aware controlled substances don't contribute to their script count may require you to transfer all your prescriptions to their pharmacy or refuse to fill only controlled substances for a patient to help justify the time and risk. Be nice to my techs.
If you're going on vacation or have some real excuse requiring an early fill give as much of a heads up as possible but be prepared for the pharmacist to not budge on it. Many will be okay with it with some conditions but some will not regardless. Bring plane tickets, hotel reservations, or notes from your doctor, they all help even if a committed addict could easily spoof them. Consider that you may need to arrange to have a new prescription from your doctor that you can bring with you or have sent to a pharmacy at your destination and call ahead to make sure the chosen pharmacy there is okay with everything. If you're picking up for someone else be prepared to be required to have their and your photo ID. Please be nice to my techs.
If everything looks clean and a pharmacy still refuses your controlled substance script, there's not necessarily much you can do except try somewhere else. You’ll need to get the hard copy back if it hasn’t been filled, bearing in mind that the hard copy can’t be returned if it was for multiple prescriptions and one was already dispensed—you’ll need to get a new prescription in this case. If it has been filled and has refills remaining, it’s eligible for transfer but only once ever per prescription.
If you do go to another pharmacy it's probably best not to mention another pharmacy said no because that tends to be a red flag, unless you have a long history at the previous pharmacy and the new pharmacist notices in which case be as transparent as possible because suddenly switching tends to be a red flag! Don't try to white lie about any reason for switching pharmacies because the other pharmacy is generally just a phone call away.
I wouldn't necessarily recommend complaining to your doctor because it probably isn't going to help and if they try to get angrily involved on your behalf it very especially isn't going to help and may also be a red flag. If your regular pharmacy is out of stock on something don't expect that most other pharmacies are going to be willing to tell you if they have it in stock over the phone; many will want to have a hard copy in front of them before they give out that information. And seriously, if you’re harassing my techs I can probably find a reason to turn you away.
In general, consistency is key here. Regular patterns are good to see and low risk from our perspective. Once you’ve established some manner of consistency with your controlled substance prescriptions things should generally be pretty smooth sailing. We pharmacists all generally wish we weren’t stuck in the position of having to gatekeep this stuff, but it's apparently something society wants badly enough that pharmacies have to have written procedures to screen for controlled substance abuse just to prove we’re not doing nothing.
The pharmacy is being really obtuse with my prescription information over the phone or for prescriptions for my friends and family, what's going on?
There you’re running up against friction caused by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is gigantic in healthcare, primarily for its strictness regarding patient privacy. If you’ve worked anywhere in healthcare tangentially at all you know what HIPAA is. For everyone else, HIPAA in a giant nutshell is all about keeping everyone else from knowing what medical conditions you have without your permission.
There’s a lot of common solutions to HIPAA requirements but it’s left up to each organization to figure out how to comply so some of the details will vary by organization or company policy. Awkward over-the-phone maneuvering is one of those; we get into weird situations all the time where we have to call to ask for someone to tell them something but have to immediately demand they prove they are who we’re looking for. HIPAA is generally very good, if cumbersome and awkward.
What can I do to avoid having to pick up various prescriptions on different days throughout the month?
Prescriptions being out of sync to pick up is one of those nature-of-the-game sorts of problems where everything kind of conspires against convenience. Things can be short-filled to match up but it often has to be done manually and can cause issues down the line. Insurance doesn’t uniformly play along if they’re strict about day supply and may result in more frequent copays than you’d have otherwise. Most chains now have programs designed to assist with this but in my experience they’re awfully clunky and I’m not sure I’d recommend them unless you absolutely have to have a specific regular pickup date. There’s scattered laws trying to more uniformly require insurance to work with these sorts of programs too but it’s still pretty up in the air. Controlled substances being involved makes things even more complicated and may require your doctor to be involved in deliberately writing short-fill prescriptions.
I’ll add my general recommendations on how to organize and track your medications with regards to refills a few sections down in the question on what to do if you run out of refills.
I’d like to change to a different pharmacy, what do I need to do?
The most absolutely pain-free way you can do this is to get new prescriptions from your doctor and have them sent or taken to the new pharmacy. Otherwise you’re stuck doing it the traditional way by asking someone else to do it for you and hoping they get it right and/or within a reasonable time frame.
Some pharmacists may be willing to transfer your prescriptions at your direct request but this is very much not the industry norm anymore and most pharmacists will require you to go to the pharmacy you are transferring to and have them send the old pharmacy a prescription transfer request by phone or fax. This process can take time depending on how much one side or the other is dragging their feet.
Here are some things to keep in mind. First, obviously transferring a prescription isn’t going to magically give you more fills. Most pharmacies either can’t or don’t bother transferring prescriptions with no remaining refills. This may mean the new pharmacy won’t have your full profile without new prescriptions from your doctor—and they won’t be able to automatically request refills on missing prescriptions.
Transferring prescriptions won’t help you get around most insurance requirements such as prior authorizations (unless that insurance requirement is which pharmacy you use). Pharmacies used to pass along insurance information as a courtesy but that’s also very much not the norm nowadays, so the new pharmacy will need to have your insurance on file. In fact, you should really be sure you have a profile set up with the new pharmacy before you even request a transfer because you don’t want to be stuck having transferred into a pharmacy that, say, doesn’t accept your insurance.
Since the receiving pharmacy isn’t seeing the actual prescription directly and is instead receiving this information second-hand from the other pharmacy, the transferred prescription is subject to any existing translation errors and any other quirks of how it was entered by the old pharmacy in addition to new potential errors introduced during the transfer. This is another reason why it might be best to have your doctor send fresh scripts to the new pharmacy if possible.
As with all things pharmacy, controlled substances have additional rules. Schedule II controlled substances (most narcotics and several stimulants for ADHD) cannot be transferred at all. Schedule III-V controlled substances that have been filled at least once and have refills remaining can be transferred, but only once ever per prescription. They cannot be transferred if they’re from a new prescription that has never been filled. (Why? Because the federal law enabling controlled substance transfers just literally says “for the purposes of refill dispensing”.) In both of these cases you’ll need to retrieve the hard copy to physically take elsewhere or have a new prescription sent to another pharmacy. Keep in mind that any hard copy containing multiple prescriptions cannot be returned to the patient if any of them have been dispensed. If it’s an electronic prescription and has not been filled, there is no other legal option than to have your doctor send a new prescription to the new pharmacy.
My insurance is requiring I switch to mail order, do I have to?
No, but usually you’ll have to manually opt out of it with your insurance and they tend to make the process frustrating to discourage it.
Unless you seriously need the convenience of mail order I’m professionally obliged to discourage it, especially inasmuch as it’s required by an insurance plan. Why? Want to guess who owns the pharmacy that your insurance’s PBM wants to require you to use? When it comes to PBMs abusing lax regulations, trying to coerce you into using pharmacies they own is really only the tip of the iceberg. In my experience insurance-run mail order pharmacies are a serious nightmare to transfer out of and if there’s any hangup with your delivery there’s not much your local pharmacies can do for you.
I’ve run out of refills unexpectedly, what are my options?
If it’s a weekday and your doctor’s office is open you’re usually best served by giving them a call and letting them know you need refills ASAP. If this isn’t the case, most pharmacies will, in this specific case only, allow you to pick up an emergency supply for a few days’ worth of medication and deduct it from the next approved refill. How easy it is to get an emergency supply may vary by pharmacist; some will instantly be willing to do it for you no questions asked, some may prefer to adhere to company policies that only allow it if there’s a strong assurance refills will eventually be authorized and filled at that pharmacy.
Again, emergency supplies are generally reserved for situations when you’re out of refills for a maintenance medication you are already getting from that pharmacy. Don’t expect even the most helpful pharmacists to take your word for it that you get the same prescription from somewhere else and will totally get it with them next time and don’t expect to be able to use it to get around insurance hang-ups or to get free short-fills on prescriptions with active refills. Expect the usual conspicuous strictness if controlled substances are involved as well, or if the medication comes in large or expensive packages that can’t be broken up.
Here are my general recommendations for wrangling your prescriptions. First, get a pill organizer, at least a weekly one. Most pharmacies sell these. I use a weekly one that’s divided into AM and PM and you can pop out individual days to take on the go, it’s pretty nice. I fill it up weekly Saturday night or Sunday morning after they’ve been emptied from the previous week and as I’m filling it up I’m checking my bottles to be sure there’s an additional 7 days’ worth after what I’ve put in for the week. If there’s less than 7 days, it’s time to request a refill, giving me 7 days (plus whatever’s left in the bottle still) to get to the pharmacy to pick up my refills—plenty of time for the pharmacy to fill it and for me to get to the pharmacy at my convenience without risk of my prescription being returned to stock.
Another thing you can do if you’re keeping close track of your refills is to request your pharmacy send refill requests ahead of time upon your last fill. Your pharmacy probably won’t be set up to automatically do this; usually refill authorization requests won’t kick in until you’ve requested a refill on something that has no refills, but you may be able to talk your pharmacy staff into manually putting in a refill request at pickup if you know you’re running out.
Lastly, keep in mind that refill requests must be approved by your doctor and approval may not be guaranteed.
I lost my medication, what do I do?
In the simplest case, if you have refills remaining and there’s no insurance issues you can just get another fill—you may have to pay for it again but, again, simplest case. If there’s no refills remaining you may need to get a new prescription or get refills authorized. Very likely there will be insurance issues if it has been too recently since it was last picked up.
Sometimes you may be able to get a lost medication override. Many insurance plans have overrides for this sort of situation and others (the other common one is vacation overrides), sometimes they can be entered by the pharmacy but other times you may have to request them directly yourself from your insurance before they can be processed at the pharmacy. These overrides are often limited so don’t expect to be able to abuse them several times in a year.
If it’s a controlled substance, expect some natural resistance to the idea that you simply lost it. If you did genuinely lose it, I recommend getting a police report, even if it wasn’t stolen (keep in mind this stuff is regulated by an entire distinct federal agency who absolutely will want to know when things go missing). After that you’re kind of at the mercy of your pharmacy’s strictness for controlled substances.
I accidentally picked up a medication that I no longer need or just otherwise have medications I no longer want, what can I do?
Check that you have what you came for before you leave the building! That’s usually where the line gets drawn for accepting returns. Any point beyond that and you’re at the mercy of how lenient your pharmacy manager is because accepting dispensed medication back is legally and ethically dicey because at some distance from the pharmacy we’re required to assume that medication may have been adulterated and is thus unfit to dispense to another patient or return to a supplier for reimbursement. Don’t automatically assume that if your pharmacy has something for you to pick up that it’s something you actually need or want.
You may be able to get a refund if you have an especially lenient pharmacy manager but if you’re past the leaving-the-store threshold chain policies typically won’t allow refunds. Chains do, however, often love it when we offer reimbursement as loyalty rewards points for not-very-subtle ha-ha-we’ll-trick-them-into-coming-back-to-shop-more-later reasons and this is a sort-of-hack-y way to get full or partial refunds if you don’t mind going this route, but it’s also something that not a lot of employees may even be aware is an option.
There’s some speculation that chains’ auto-refill schemes are designed broadly to cause this by filling scripts that probably shouldn’t be filled to trick people into picking up. Some places have laws to address this. This is another reason why you might consider not leaving your medication on automatic refill.
If you just generally have medication you don’t want the FDA has several resources for what to do. Some old school methods like flushing them down the toilet are actually not really a good idea, especially from a public health perspective. If you’re going to just toss them without putting any effort into it just leave medication in the bottle (don’t forget to remove the label with your name and info on it if you’re concerned about privacy) or throw them into some other durable container so they can at least be separated further down the line by waste disposal. Common advice for medication disposal includes mixing them in with cat litter or coffee grounds or some other unpalatable substance before disposal. There are some products that work deliberately to this effect as well and may be available (often as free handouts) at your local chain. Some pharmacies may also have a public medication disposal bin for collection that’ll do all the work for you as well.
Why is the pharmacy constantly bugging me to refill medications I no longer need or have no need for any time soon?
It’s been touched on here and there before, but a big part of what drives pharmacy business is prescription volume. Your pharmacist wants you to be adherent with your medication—to be taking it every day as directed by your doctor and refilling it whenever you run out—but your pharmacy as a business is mostly interested in the latter half of that. Thus, your chain pharmacy will have a whole host of automated refill reminders and alerts trying to keep you on the wagon. They’ll often be trying to move you towards 90-day supply fills as well, since it allows us to do the work for 3 months just once. Automated alerts don’t do a good job of keeping track of how you’re taking your medication, so if anything changes it tends to get thrown off very easily.
There’s another growing aspect to this: Medicare health insurance providers have done kind of an impressive job unloading their responsibilities with regards to Medicare Star Ratings onto retail pharmacists by contractually forcing pharmacies to take care of it for them by tying the star ratings to reimbursement rates. So in addition to the barrage of automated alerts and reminders, contracts with health insurance providers want us to be manually bugging Medicare patients regarding their medication daily as well.
There’s some real unfortunate irony here because professional organizations have been lobbying for a long time for comprehensive medication therapy management to be federally recognized and billable to Medicare so we could get paid for doing it and now Medicare providers are able to just require us to do it for free by threatening lower reimbursement if we at the pharmacy don’t hit their star rating goals for them. If you’re wondering why the reminders and alerts tend to get kind of excessive, this is absolutely a part of why.
I’d like to get a vaccination, is there a reason I shouldn’t get one at a pharmacy and does it matter if I schedule an appointment?
No, there’s really no reason you should avoid getting vaccinations at a local pharmacy aside from general-pharmacy-problems considerations. The busier your chosen pharmacy is the more obstacles there may be to getting it done in a timely manner, and it can often be just as convenient to have it done by your regular doctor during a routine visit (if available), at an occupational clinic, or a designated public vaccine clinic or event, but for most people and most pharmacies you could expect things to be normal-prescription-pickup levels of convenient.
If you’re having it done at a pharmacy that you don’t normally pickup prescriptions from, you might want to be sure you have your insurance card with you. Many vaccinations will be zero- or low-cost to you and are often covered even without insurance via public programs, but it’s marginally better to have insurance on record to pick up the cost.
Regardless of whether you have it done at a pharmacy or elsewhere, you will be asked basic screening questions, generally things that are designed to screen for potential severe immediate reactions or rule you out of needing the selected vaccine. Stuff like whether you have a weakened immune system or have received other vaccines recently are important for their effectiveness. There will be questions about basic allergies and whether you’ve had reactions to previous shots to gauge risk of the severe reactions occurring, but regardless your pharmacist will be required to have a first-aid kit nearby and be CPR certified every 2 years for eternity.
You should schedule appointments if you can take the time, even though you generally don’t need to and nobody will care if you show up at precisely the correct time. It’s useful to us behind the counter for a couple reasons, chiefly to ensure we have the requested vaccine in stock but it’s also nice to have an idea of what the workload is going to look like for the day.
II. Prescribers
A general foreword for this section: a lot of what will follow here is going to include echoes of topics covered in the first section so if you happened to skip right down here, I’d recommend going back and reading up because I may be referring back to ideas covered there.
The pharmacy is refusing to send refill authorization requests or contact us for a new prescription for whatever reason and my patient is upset, what’s going on?
There are a couple basic reasons why the pharmacy may not be able to contact you regarding prescription authorization. Going back to transfers, if your patient has changed pharmacies without their whole file following them to the new pharmacy, it may not have some prescriptions on file to follow up on. In some states, contacting a doctor for a new prescription that the pharmacy has never had on file before may be prohibited.
Prescriber selection at prescription entry can be dicey. Many prescribers will have multiple entries for separate offices or clinics, and these will have different corresponding phone or fax numbers. If an incorrect prescriber entry is selected (even if it’s the correct actual prescriber), communication info may be out of synch in a way that interferes. Pharmacy software may be pulling information from NPI, DEA, or state board databases so it might be helpful to periodically make sure all entries for those are up to date. If there seems to be common communication problems with a particular pharmacy, you can always have someone call to verify all the numbers match and to clean up anything that’s out of date.
If you’re wondering why the pharmacy might be reluctant to call it’s been covered a few times in the above segments for patients. If I spend 3 minutes on each of 20 prescriptions that need fixing in a day that’s an hour out of every 8-hour shift I spend doing only that and we’re already being optimistic that everybody picks up the phone and has swift solutions for each of my problems.
If you’re willing to be proactive, you as the prescriber have some options for potentially alleviating this that aren’t available to anyone else. If you’re able to provide a direct line straight to someone at your clinic or office who can assist with prescription issues quickly (or to you, if you’re somehow okay with that) that’s wonderfully ideal for us. If you want to set up an alternate communication channel like say text or email you might be able to get individual pharmacists or pharmacies to play along but expect that chains aren’t going to be set up to help you do this.
Most pharmacy phone systems have a separate menu for prescribers, but it may be hidden from the default options in order to keep regular patients from using it (they will definitely blunder into it constantly anyways). This will always include some sort of voicemail, which is handy if you need to communicate one way and faxing or e-prescribing is not an option; dropping your called-in prescription in the voicemail is one of those time saving win-wins for everyone as long as you and your office staff know how to get there (sometimes this is supposed to be set up to recognize a prescriber’s office is calling in but we’ve already covered how that can go awry). Prescriber menus will also usually have an option to send you straight to the pharmacist’s workstation, though this won’t guarantee that it’s the pharmacist who will pick up the phone first.
A patient’s prescription requires prior authorization, why didn’t the pharmacy tell me or why have they not notified me, what’s going on? Is there a way to be sure ahead of time that a prescription will be covered by a patient’s insurance?
The pharmacy’s software may not be configured to automatically notify you if something needs prior authorization so you may not be notified unless someone manually sends communication. Since from our perspective prior auths are a complete toss-up with regards to whether prescribers will ever do them, expect that the pharmacy isn’t going to put much effort into repeatedly notifying you one is required after sending a PA request the first time. Expect that these notices will generally always go by fax since only the deadest of pharmacies will have the kind of time to call for this. Expect any amount of the communication issues outlined above.
Unless you have access to actual claims adjudication software there may not be a clear, low-effort way to know ahead of time what will and won’t be covered. I’ve had prescribers indicate to me that they have tools built into their charting software that can check for them but in my experience they tend to frequently be incorrect. Technically, insurance drug formularies are open to the public so if you wanted to you could go searching for those and cross-check manually as long as you know your patient’s drug coverage but it’s also still possible that there’ll be surprises at adjudication in the pharmacy. Having manufacturer coupons on hand can help but aren’t always a clean preventative solution.
If you do want to start collecting patient’s drug coverage, keep in mind it changes at least once a year and any time your patient is changing insurance they’ll have new drug coverage so it might be something you’ll want to recheck at every patient visit. I’d recommend doing this because if something does need a PA you don’t need to bug us for their drug coverage info since you’ll already have that on hand. Grab a photocopy of your patients’ insurance cards; the information you’ll want to have on hand is the RxBIN, RxPCN, and ID number plus the RxGroup if there is one—if a patient has new insurance and you find out before we do only giving us the ID doesn’t help! The card will also usually have phone numbers for who at the insurance to call for questions.
Another option is to call the patient’s pharmacy and request a test claim. It’s time consuming and somewhat technical so you’ll be rolling the dice on whether pharmacy staff will both know how and be willing to do it, and they may not be willing to do it for a dozen prescriptions at a time. If they’re not our regular patient, we also need to have their insurance information—which you can provide if you’re collecting it!
If you think you have an authorization squared away and the pharmacy says it’s still rejecting, I’d encourage you and your office staff to believe them by default. Reprocessing a reject is trivially easy and approved prior authorizations don’t typically need the authorization number to be manually input, so the odds of someone making a mistake on our end is not very high unless some unusual specific override code is required (or if it’s for a program that doesn’t use standard prior auth framework). Double check your paperwork and call the insurance if you need to. I see doctors accidentally get the wrong drug approved more often than I’ve seen my techs fail to correctly click the reprocess button. Don’t forget to check the expiration date on those authorizations either, it’s always a thrill when I get faxed an approval letter that expired 5 years ago.
If the patient’s insurance is claiming something doesn’t need a prior auth but the pharmacy is telling you it does, this may mean there’s some sort of basic override that’s getting missed, in which case you can either try to coax those codes out of the insurance or implore the pharmacy to forward you to their tech or pharmacist who most knows how to wrangle insurance overrides. Reminder that this person may not exist depending on how rapid a given pharmacy’s employee turnover is.
The pharmacy has refused to fill a controlled substance prescription, what is going on?
See the relevant section in the patient section above for a detailed explanation of what’s going on from our side of things. As a prescriber, you have more options for tilting the priors in your patients’ favor than they do. If you’re able and willing to provide documentation, do it copiously. ICD-10 codes are a pretty standard minimum requirement, but the absolute dream would be if doctors sent us entire patient charts. Establishing a professional relationship with your local pharmacies or individual pharmacists can go a long way. If you’re keeping hawkish track of your state’s PDMP the same way your pharmacies are (and you should be! fun fact: it’s now required by law in California et al.) let them know you’re proactively on the lookout too.
Definitely, definitely don’t try to make threats if things aren’t going your way. And please don’t lie to your patients about whether we have to fill their controlled substance because you or they say so—only the dullest-witted and newest-of-the-new pharmacists aren’t going to be aware of the actual law. Corresponding responsibility means that our licenses are on the line if you screw up, and can be stretched to accommodate virtually any denial, so being pushy and trying to appeal to authority is only going to hurt your chances. Pharmacies can and do occasionally blacklist entire prescribers from controlled substances for poor behavior and prescribing habits so, again, wouldn’t recommend it. Be nice to my techs.
Also keep in mind that pharmacies will be strict about fill dates for controlled substances even in the case where insurance is good to pay for the prescription. This is usually based on the day supply, which is thus very important to get right! For pharmacy (and more importantly, for insurance), day supply is meant to be calculated based on maximum usage. So, say you write a script for Norco 10/325 1 tablet by mouth every 4 to 6 hours #150. That translates to 4 to 6 tablets per day but both the pharmacy (and insurance) assumes day supply at the maximum 6 tablets. If you are assuming day supply averages out to 5 tablets per day and your written quantity was meant to reflect a 30-day supply this may be absolutely unclear to anyone but you. If this is your intention, communicate with the pharmacy!
It’s best not to write a prescription for a controlled substance one way and tell the patient to take it more frequently than written, because the pharmacy may hold them quite strictly to what’s on the prescription. If you’re trying to wean a patient down from something and your chosen method is just cutting some quantity off the prescription, make sure the pharmacy knows that you’re intending for day supply to stay the same. Before I caught on to these sorts of weird day supply misunderstandings, I thought it was awfully strange that doctors thought just dispensing 5 less tablets was doing anything when their patients were literally just picking it up another day or two early anyways.
The pharmacy has refused to fill a non-controlled prescription, what’s going on?
There’s not much to add here that wasn’t covered in the patient section. Unlike controlled substances, there aren’t a lot of situations where a pharmacist can (or should) flat refuse non-controls outside of a few ultra-rare cases. A pharmacy may refuse or be otherwise reluctant to fill some broad groups of medications such as over-the-counter medications (since they’re rarely covered by insurance and eat labor time) or compounds (for a variety of reasons including onerous documentation requirements and, again, they tend to be time-consuming).
Is the PDR good enough for prescribing? What other kinds of drug resources do you recommend?
PDR is totally fine; I’m not going to say a lot of the standard prescriber references are bad but there are definitely references we prefer that are more tailored for someone wanting more in-depth detail on drugs. The original version of this response was going to be a snarky take on the classical pharmacist position that the PDR is trash and how we secretly have no respect for anyone who uses it but then I took a look at PDR’s publicly available drug monographs and they’re surprisingly complete! It’s reportedly curated by PharmDs, so I guess this isn’t outrageously surprising, if that’s what you’re using it’s alright. In the years since I originally wrote this I’ve even used it in the interim both at home and on the job after I lost access to Facts & Comparisons. GlobalRPh is another excellent freely available resource that has a variety of pharmacy tools and references.
A lot of the go-to pharmacy references are maintained by organizations that are all over health science so chances are there’s some overlap between them and whatever else you might already be using. The old school drug reference LexiComp—which is still publishing physical drug reference handbooks—is owned by Wolters Kluwer, which also owns Ovid and UpToDate; their online version most pharmacists will be familiar with is Facts & Comparisons, which is my personal favorite. The hospital I worked in as a student preferred Micromedex, which is run by IBM Watson Health and is also generally pretty good. A lot of institutions have access to Clinical Pharmacology which is owned by Elsevier and is predictably lower quality. The American Pharmacist Association’s Handbook of Nonprescription Drugs is a top tier resource for over-the-counter treatment and their NAPLEX review books are one of the best ways to cheat if you want to quickly brush up on clinical pharmacology in general without buying a bunch of textbooks. My go-to reference for OTC herbal/supplement products is Examine.
A good drug resource will provide, in addition to the dosing, adequate information about common dose adjustments, basic contraindications and precautions, important drug interactions, and precise details on available dosage forms and administration. Some handy secondarily useful information you might want to look for is FDA approved indications, common or severe side effects, storage or stability, and effects on pregnancy and lactation. Specific drug pharmacology and kinetics can be useful for predicting theoretical drug behavior on the fly or explaining unusual results but may not be super useful for day-to-day practice. All the references mentioned above will have these and more. Facts & Comparisons and Micromedex have pretty good comprehensive listings of available products by drug in the US too.
The patient received their prescription but some detail about it was totally wrong! What happened?
Mistakes happen! We do our best but it’s a statistical inevitability that some will make it through. If you go all the way back up to where I described what it’s like processing prescriptions, there’s compounding risks for errors at every step. Most pharmacies will have policies and procedures in place to catalog and correct mistakes, so do let us know if word gets to you before us! Looking for blame isn’t strictly helpful but looking for systemic problems is essential. If you don’t already have sympathy for the sorts of conditions and constraints we’re working with over at the pharmacy there’s probably not much else I can say here that’s going to inspire it, but do try to appreciate there’s as many hundreds of opportunities for things to go wrong for us as there are for most other places in medicine and it takes more than angrily demanding perfection to overcome that.
If the prescription was written incorrectly to begin with, don’t lean on the pharmacist cleaning those up for you. Definitely read back everything you write at least once and triple check anything you send by eRx because a majority of them we receive come through really mangled and have to be liberally corrected so intention may get lost somewhere. E-prescriptions tend to get kinda fun; some of my favorite examples of them going bad (all verbatim):
Ibuprofen 800mg take 1 tablet by oral route 12 times every day with food
1 TABLET ONCE A DAY ORALLY 30 DAY(S) ONCE A DAY ORALLY 30 DAYS Once a day Orally 90 days
Prescriber comment: TAKE 1 TABLET BY MOUTH EVERY DAY
Diabetic test strips: insert 1 daily by percutaneous route 2 times every 14th day for 3 months
1 tablet Once a day as needed. Do not take daily, take with food Orally 90 days
Prescriber comment: spanish to affected area
Take 1 tablet daily for 1 week then increase to 1 tablet daily
TEST STRIPS FOR CURRENT METER STRIP TEST STRIPS SKIN PRICK
Ezetimibe 10mg #8100
As Needed for Take as directed
Xarelto
Diagnosis: constipation
Chantix
Diagnosis: pain in right knee
I think most of us eventually hit a point in pharmacy veterancy where you just have to accept that doctors are going to write weird crazy stuff and insist on it, you even get to a point where you can spot unusual patterns in the weird, crazy stuff. So unless it’s something really outlandishly wild or obviously dangerous only the fresh grads and bright-eyed newbies with uncrushed souls are going to be likely to bug you about it.
Speaking of that, why does the pharmacy seem to be constantly getting hung up on seemingly trivial stuff?
This is certainly a quirk of the profession. The simplest short answer to this is that the professional culture trains us to be incredibly skittish about everything. I don’t have a good answer why or how this came to be that isn’t some broad speculation on the sorts of personalities that go into pharmacy or about how our profession occupies a very awkward niche in the greater medical world.
But here’s an unnecessary extended metaphor I’ll construct to explain this (pun preemptively intended): if doctors are the architects, pharmacists are the people who chose to go out of their way to know everything there is to know about structural supports out of some awkward hope that if someone ever has an obscure question about balusters they’ll go straight to the columnists.
Now every so often a cathedral collapses and kills several people, so society in general recognizes the vaguely nontrivial importance of having the columnists around, but also no competent architect doesn’t know a solid minimum of what they need to know about structural supports to do their jobs so in practice the columnists are just left to oversee pillar shipments and storage most of the time.
The academic columnists, their professional organizations, and the various state boards of columny decide to deal with this by lobbying to “expand the role of the columnist”—by having all new aspiring columnists study up on how to build small houses on the side, except that nobody really wants a house constructed entirely out of spare posts either so it starts to become a problem when a bunch of the loudest columnists want to be able to charge full market value for novelty pillar-houses when most of the blue-collar practicing columnists would be happy just be working with some higher quality building materials and fielding the occasional structural-support-related consultation. And the latter group is also getting concerned that there’s starting to be a bit few too many clinically-trained columnists around relative to the demand for actual columns and it’s driving down column-maker wages without improving column quality.
...what?
Anyways, the salient point here is that new columnists today are trained and capable of putting together a competent building in the same way we currently trust, say, architect assistants and nurse architects to do so without the full scope of architect training, and yet serve a society that only fleetingly and begrudgingly recognizes their importance, so they tend to be kind of insecurely trapped in a mindset that they’re only valuable for delivering nice stacks of marble.
Stop that.
Well, so here’s what I mean. Most states nowadays have laws supporting therapeutic substitution by pharmacists, implicitly acknowledging the degree to which we’re trained. Pretty much nobody does it, even at times when you might think it might be helpful. Why? Because it’s just not worth the potential drama. Doctors flip out at us if we deviate from what they want at all and patient’s flip out at us if we get in between them and their doctor’s divine intervention at all. There’s just no glory in it; it seems to me like society wants someone gatekeeping “dangerous” medication but also wishes there wasn’t even a gate to keep. Imagine you get your freshly minted MD and you’re not allowed to do anything at all without your attending signing off on it except now that’s the situation you’re stuck in for the entire rest of your life.
So if it seems like the pharmacy is bothering you a lot over small and trivial things, (it’s not vindictive angst in the way my tone is probably implying here,) it’s because all of the current professional mechanisms we’ve engaged to try to prevent that from happening have ultimately failed. We’re trained to recognize when things are suboptimal, so of course we’re going to catch the small stuff, but with the risk/reward profile being so outlandishly unfavorable, why wouldn’t we send it back for you to deal with instead? There’s going to be variable risk tolerance depending on the personality of individual pharmacists but in general nobody has the guts to do anything about anything without the prescriber’s checkmark. And frankly it’s probably for the best that we’re not going maverick on everything either, but the resultant output tends to most frequently be “screw it I ain’t filling this until we get a call back from the doc’s office”.
Here’s where I’m going to drop a half-hearted sales pitch to be like, hey! If you’re an independent physician consider hiring a pharmacist and then just have them deal with all the dumb pharmacy stuff! Prior auths and insurance shenanigans throwing a wrench in your plans? Throw a pharmacist at it! Retail pharmacies giving you guff? Make two pharmacists miserable at a time! Tired of having to call someone to find out if flurbiprofen interacts with Kapspargo? Et cetera!
Maybe, what is the scope of pharmacist training and education? (this question formerly “Why do we even have pharmacists what do you guys even do how long until you’re all replaced by robots?”)
Back when I was in school in the 2000s it was still a 6-year Doctor of Pharmacy (PharmD) program. Yes, we all know that should technically be a masters, most of us roll our eyes at the pharmacists demanding everyone call them “doctor” too. In the 6-year program, a PharmD was 2 years pre-pharmacy before entry into the program proper, 3 years of professional classes, and 1 year of experiential rotations with an optional post-graduate 1 to 2 years of general, then specialized residency. Most pharmacy programs have standard extracurricular experiential requirements as well (we have to do additional unpaid internship rotations while we’re still in classes) and those hours requirements have been skyrocketing over time. From what I understand most pharmacy schools have been trying to transition to 7 or 8 year programs but it seems to be more front-loaded on the pre-pharmacy end (or rather, I was under the impression this was the case, this seemed to be where academia wanted this to go in the early 2010s when I graduated but looking around now it seems most colleges of pharmacy are still 6 year programs, with expedited 5-year programs being somewhat common now even).
The program classes start with the more advanced biochemistry and pharmacology the first year and transition towards specialized therapeutics over the next two. For my program, the first year was lots of biochemistry but also the basic intro to pharmacy and medical stuff (for example, had an entire semester class on different kinds of drug delivery systems like how extended release is different from immediate release). The second year began the heavier-duty pharmacology broken down into groups by very generalized health specialty (metabolic, hormonal, circulatory, pulmonary, neurological, GI, and so on) and the more advanced general pharmacology, classes on kinetics and bioavailability and such. Third year focused more on therapeutics by more specific health specialty (cardiology, psychiatry, oncology, nephrology, pediatrics, infectious diseases, et al.), looking more at where medication therapy fits on the entire spectrum of diagnosis and treatment as well as monitoring for efficacy and side effects.
So actually, let’s take a moment here to construct a less sarcastic sales pitch. If you’re an independent physician, consider hiring a pharmacist for your practice for immediate continuous access to a heavily trained medical professional that can really, seriously, honestly do a pretty decent-sized chunk of the same kind of busy work you’re trained to do—for you. In the same way you hire a physician assistant to make your basic patient physical workups easier, you can pick up a pharmacist to take some of the routine disease state management workup off your plate—especially where medication is involved. We get a frankly-kind-of-insane-and-borderline-pointless amount of ancillary medical trivia from pharmacy school too; I remember having not-insubstantial exams on stuff like reading EKGs, perform physicals, and differential psychiatric diagnoses. There’s a decent chunk of states now where we can prescribe under the same sort of physician supervision that PAs and NPs can. The running theme here is that if you feel at all overworked, having a pharmacist on staff can help with that.
You’ll notice the above includes very little training for what one might recognize as retail pharmacy experience. No counting by fives, no customer service and laughably little personnel management training, no dealing with insurance. Some of that comes from a mix of in-class practical labs and required pre- and in-rotation internship experience (plus job experience if you go out and get it on your own). However, most places don’t let interns handle pharmacist duties so, for many pharmacists, meaningful retail experience as a practicing pharmacist only comes after graduation. I want to highlight this a little to make the point that if you do want to hire a pharmacist, retail experience may be very valuable in a way that modern pharmacy school—which is more focused on clinical pharmacy practice—sort of undervalues. An experienced retail pharmacist will be bringing in customer service and personnel management experience so if you need someone to keep your office staff on task you can find a spot for them behind the front desk. Since they’re also more likely to be in tune with retail pharmacy issues they’re a natural pick to handle your prescription call-ins and field questions and verification from the pharmacy. If they have decent experience handling insurance issues, a pharmacist can help you see coverage problems coming or deal with them when they’ve surfaced. Even if you don’t want to commit to an entire pharmacist, an experienced retail pharmacy tech will have a lot of the same non-specialized experience described in this paragraph as well. I’ve already seen a few local offices and clinics advertising to hire techs to handle their prior authorizations.
I’m highlighting the value of retail experience because if you do decide to go this route chances are you’re probably going to be tempted or advised to hire for pharmacists with clinical experience or residencies, and while pharmacists with that sort of experience are valuable, every PharmD will have some amount of clinical experience just because our academia is obsessed with it and it ends up being virtually all of that third year and most non-outpatient rotations.
III. New/Non-Retail Pharmacists, Pharmacy Technicians, and Students
For this section, I’m going to be more direct in disclaiming that everything below is more editorial-with-autobiographical-flavor and maybe more scandalous with regards to professional practice than the previous two sections were intended to be. If you wanted to stop reading here you’re good to go since the original explainer didn’t even include everything below and it will probably be less relevant to most people than even the prescriber section. Either way, thanks for reading!
I’m about to start working/doing a rotation in a retail pharmacy for the first time, what should I expect?
Pain.
Especially if you have no retail/customer service experience prior.
You know how some countries have mandatory military service? (Actually, a lot of countries, dang!) I feel like if we had something like mandatory retail service things would be, well, I don't know if things would be better but they would definitely be different.
I’m going to cover a few more specific things in just a moment so let me mention some things I won’t address below. Since you’re asking this question, let’s assume you’re going into it in a near-worst-case-scenario like I did: I mostly coasted through pharmacy school assuming I’d graduate and settle into hospital or clinical pharmacy without doing a residency. Oops!
I had two required retail pharmacy rotations. Both were worthless. The first one accepted I wasn’t interested in retail, shrugged, mostly let me waste time on an office computer in the back, and then complained that I didn’t do much work (admittedly, mea culpa). The second did that thing where they only let you count pills and counsel patients so the staff pharmacist doesn’t have to and then complained that I spent the entire rotation only counting pills and occasionally counseling patients (much less mea culpa). (How I ended up in retail anyways is a longer but equally stupid story.) I don’t know why outpatient pharmacy preceptors don’t let their students act like pharmacists; I’ve had students on rotation in my pharmacy since graduating and it seems to be the same everywhere.
The first time you go through training and onboarding (assuming you’re lucky enough to not just be thrown into the fire) do your best not to take it for granted. Learning the local corporate policies and software are some of the most important first steps you can take. Rotations should have taught you not to be afraid to ask questions and make huge mistakes to learn from, if they didn’t now is the time to learn to embrace that fear.
This will feed into the next question but as soon as you start your first job in pharmacy you’ll need to decide which part of the letter-of-the-law vs spirit-of-the-law spectrum you land on. Knowing as many of the relevant laws you can hold in memory is extremely important in either case, but especially in order to know how to bend them safely. This isn’t something where I can really advise you on what to think (even though I’ll have some thoughts on deciding how to think in just a moment). Ultimately, it’s something you’ll need to decide for yourself. Don’t be surprised if your thoughts on this shift over time.
Many pharmacy tasks are pretty intimidating the first few times but get easier the more you do it, especially vaccinations, order entry, and dealing with insurance. Expect that everything will take time to feel comfortable doing.
What are some rookie mistakes I should try to avoid?
A lot of fresh grads have been insulated from having to be the One That Makes Decisions and thus having to be at peace with all of the potential consequences, nor have they typically had to think about the letter-vs-spirit-of-the-law idea mentioned previously. Or even how to even make sound decisions under uncertainty. So, let’s start with an introduction to Bayesian reasoning for pharmacists.
Alex comes up to your pharmacy window—brand new patient—and hands you a prescription for amoxicillin. So you ask him if he has any medication allergies. He says he doesn’t know. You ask him if he’s taken amoxicillin or any other penicillins before. He says he doesn’t know. If you dispense the prescription, what is the percent probability that Alex has an anaphylactic reaction to the amoxicillin? Have a number in mind, it doesn’t have to be a correct number, just make a guess and keep it in mind. Alright, next.
Brenda comes up to your pharmacy window—brand new patient—and hands you a prescription for amoxicillin. So you ask her if she has any medication allergies. She says she doesn’t know. You ask her if she’s taken amoxicillin or any other penicillins before. She says, “Oh yeah, penicillin! You know last time I took that it put me in the hospital, almost completely closed my throat up, I almost died! It was awful!” If you dispense the prescription, what is the percent probability that Brenda has an anaphylactic reaction to the amoxicillin? Again, just note the number for now. Next!
Charles comes up to your pharmacy window—brand new patient—and hands you a prescription for amoxicillin. So you ask him if he has any mediation allergies. He says no, he does not. You ask him if he’s ever taken amoxicillin or any other penicillins before. He says, “Oh yeah, been on amoxicillin a few times, always worked great, no side effects!” If you dispense the prescription, what is the percent probability that Charles has an anaphylactic reaction to the amoxicillin?
Now compare those numbers. This wasn’t any kind of trick question, what you should notice is that Charles’ number should be somewhere lower than Alex’s number, which should be somewhere lower than Brenda’s number. The salient point here is how more information changes the projected likelihood of the outcome. Bayes’ theorem mathematically formalizes this interaction; if you had real numbers to represent every component of the above scenarios you could insert them into the formula and get real numbers out.
By now you’re probably thinking, well duh, obviously knowing more changes your prediction. The point is, A) you should try to learn to think in probabilities that an event will occur for everything ever, B) you should learn to notice what kind of information changes your guess and how it changes that guess, and C) that you’re allowed to make decisions under uncertainty based on your best guess of what the probability is—as long as that’s a due-diligence good-faith best guess.
Brenda and Charles are easy choices here, but how about Alex? You can try asking more creative questions to see if you can get more relevant information out of him, but we’re eventually going to have to make a choice. So, how common are anaphylactic reactions in the general population? Pretty low, right? Do the likely benefits outweigh the presumed low risk? Almost certainly, right? We’re permitted to conclude that it’s very likely it will be safe for Alex. Additional important questions: have you adequately, honestly done your due diligence to determine your priors for this? If your risk concerns are high enough, have you counseled Alex on the potential adverse outcomes and what to do about them? Have you bought your liability insurance yet?
You probably shouldn’t use this power for evil, but you can mostly bend it to your risk tolerances.
The thing that really marks a newbie is how literally they’re still taking everything from pharmacy school. Let’s start with the obvious one: counseling. (Strap in for round 2 of ranting about counseling requirements.)
Once you’re out of pharmacy school and passed your board exams there’s no longer a theoretical Spirit of Strict Pharmacy Practice looking over your shoulder, making sure you hit every single proscribed counseling point every time for every patient for every new prescription. Again you should still know these points because it will eventually come up again, probably. But now you’re allowed to think about what your patients want, what they would prefer, what it benefits them to know, and where giving too much information is counterproductive. You’re allowed to notice that a new prescription isn’t always a medication they haven’t been on for months or years. You’re allowed to consider how you treat your patients affects their relationship with you, and that infodumping every possible side effect might be undermining that relationship.
People don’t normally come to the pharmacy with a lot of free time, they’re not always going to have questions about the things they ought to have questions about but that’s fine. Closed-ended questions aren’t verboten. Again, there are plenty of people who are going to be best-served by the tried-and-true “do you have any questions about your medication?”
Still, recognize that there’s important things they need to know no matter what.
When people do need or want to know things about their medication, speak to them like a person instead of regurgitating a monograph. Give them the useful bits especially, think about what you’d want to know most if it were you. Never give them information about a side effect without telling them what to do about it, even if it’s a boilerplate “tell your doctor”. Lisinopril is usually pretty safe but can cause cough, if you find that it’s troublesome let your doctor know because there’s basic alternatives. Expect that escitalopram will take a few weeks to a month to start working, and it can affect your sleep in any way so tailor the time you take it to whether it makes you drowsy or wakeful. Keep the amoxicillin suspension in the fridge and give it with food to help prevent upset stomach.
Some patients will be at their wits’ end or hopelessly lost and need a lot of your time, so be prepared to recognize this and to be able to divorce yourself from your busywork to give it to them.
In any case, just make sure the paper trail says you counseled them.
You don’t need to contact the doctor for every minor mistake. It’s cool to let #8100 with 86 refills ride, just quantity dispense it and move on—that prescription’s still going to expire in a year regardless. I promise you it doesn’t matter whether the doxy is hyclate or monohydrate. Their doctor doesn’t need to rearrange all their medication for a patient on a statin with fluconazole, just tell the patient to skip the statin on the night they take the azole. Time management is extremely important, try not to call when you can fax.
Never void a prescription because something is incorrect or needs to be addressed, do whatever your system needs to take it out of the workflow without closing it and move on. Don’t forget about it either, once you notice something is wrong it is now your responsibility to ensure it eventually gets fixed and dispensed. Leave reasonably detailed notes for when your colleagues might have to pick up where you left off.
Never let patients bully you on controlled substances, fill dates or otherwise. This is one of the rare cases where you’re relatively immune from customers complaining up the chain since your employer can’t force you to violate federal law.
Never mistreat your techs because they’re your lifeline and are also best positioned to make your life miserable. Yes, they’re not all perfect angels but start from the default assumption that they are.
Learning to pick your battles is the first step to veterancy.
I’m brand new to customer service and pharmacy school taught us literally nothing about it, help?
This is going to be the toughest part of starting pharmacy from scratch, especially if you’re naturally introverted like I am. I got lucky though, because I did improv in high school.
If you have no idea what I’m referring to, look up some bits from Whose Line Is It Anyway on YouTube, they’re probably the most widely known short-form improv comedy groups. Improv and customer service are both learnable, practicable, technical skills with some useful overlap.
Improv has a lot of soft rules, ways that you’re supposed to develop a scene that facilitates maintaining an easier flow state that makes for entertaining skits. Good improv between two people can look like as mundane as a regular conversation if you don’t know that it’s fictional and being made up on the spot.
These kinds of rules are going to be difficult to demonstrate without showing so maybe go back to YouTube for more “how to improv” type stuff but let’s try. One of the rules you may have heard of is avoiding negation. One of the quickest ways of breaking a scene in improv is to deny the scene already being constructed by your partners.
“Hey John, I see you’re doing the dishes over there.”
“Nope, I’m conducting an orchestra.”
And then the first person naturally has less to work with or has to work harder to react to you and has to scramble to adapt in a way that doesn’t lend itself to maintaining good flow. The preferred alternative to this is to “yes, and” (or “yes, but”, etc.) which helps keep the scene moving and also tends to just be funnier.
“Hey John, I see you’re doing the dishes over there.”
“Yep, and I’ve gotta say it’s awfully difficult to wash dishes while also conducting this orchestra.”
Now you’ve already got some pretty alright situational comedy started.
Anyways, customer service is a lot like this, you want to try to get into these kinds of conversational flow states, because it feels pretty good for everyone involved and feelin’ good is the paramount goal in customer service. Doing this well is a skill you’ll have to practice. Always be thinking of where you want an interaction to go and try to build a rhetorical road to get there. Often times it will be as simple as “I want to sell this prescription and get them out of my line” or “this person is weird and off-putting but has a question and I need to get through it so I can get back to work” and so on. If it’s not something that comes to you naturally, learn to build up an internal library of generic reactions to common generic situations and stories that you can use to buy time.
Also, having in mind that negation is what shuts down conversation flow can be a useful tool for putting the brakes on lines of conversation that you don’t want to continue. You’ll need to be very judicious in applying this, learning to say no diplomatically is also extremely valuable. Learn to embrace your inner corporate customer service representative. If you’ve given an answer to an inquiry or presented the only available options for them to select from, deadpan repeat your answer ad nauseam. Sometimes the best ways to dead end a bad interaction is to present a curated list of choices and refusing to entertain other options, even if they think they’re being clever by trying to change the question or just being overbearing. A drug isn’t currently available but a patient wants it right now “well, you can either wait until it arrives in our order in the next few days or we can transfer your prescription to another pharmacy” but I want it right now “I’m sorry, but those are the options currently available to us right now.” (Then repeat the last statement in a loop as needed.)
Most of the high stakes customer service situations will be handling complaints and like any disaster there’s no real way to get good at it without just doing it. If there’s a genuine problem or mistake to correct then there’s a generic acknowledge/apologize/offer solution/swear it won’t happen again template to follow. Else, your goal is usually to try to get them to go away while not being upset enough to cause problems for you with your employer. As with improv, it’s best to always be shifting the interaction forward (or rather, you’re at the most adverse risk if you let the conversation end abruptly or stagnate in an especially sour spot). Usually some form of appeasement works but not always, and very frequently the appeasement they’re looking for is demanding you to compromise on things you would especially not want to compromise on. Try to avoid escalating to a higher level employee unprompted if you can avoid it, but do so immediately if they want to speak to your manager. (Try not to be the manager.) Don’t be afraid to be maliciously unhelpful to problem customers. Making it clear that you can’t be pushed around does marginally help decrease the incidence of customers trying to push you around.
Since we can’t do anything that jeopardizes our licenses or breaks legal requirements, pharmacy is sort of unusual in customer service in that we have more leeway to behave like the customer is definitely not always right. Especially, as mentioned before, if controlled substances are involved.
If you’re able to identify coworkers who are really good at wrangling customers, you can get some value out of observing and imitating them.
Empathy can help a lot as well but isn’t always completely reliable and is its own separate other set of skills. Beware that it might take you to dark places when you realize how many regular people don’t treat retail and service employees as humans.
Dealing with people on the phone is an additional subset of these skills. Knowing how to end conversations is even more important because people are at more liberty to behave poorly without being in front of an audience in the store. Straight hanging up on people is an extremely rare option since it will virtually always cause problems for you later down the line (tends to only be safe when someone has started to get verbally abusive). My go-to favorite here is some variation of “is there anything else I can help you with at this time” into a goodbye if they can’t quickly come up with a reasonable additional distraction.
As with most things this will all come with time but expect it to be a rocky road starting from scratch.
I’m worried about board inspections or regulatory upkeep, what do I do?
If you’re working for an indie, you’re kind of on your own here. If you’re working for the chains they will have tons of policy and procedure on what to do, and will probably have everything set up for you, you’re only major concern will be knowing where to find it. Sometimes even the inspectors will have been through dozens of these with your company and might even know where to find the relevant policies and procedure. Usually there’s info on your company’s intranet somewhere but it’s also often in a binder in a dusty corner somewhere. You’re typically supposed to start by calling your district manager and they’re supposed to freak out and try to tell you what to do.
Basically, don’t panic. Keep in mind you’re supposed to check their IDs and verify they’re actually inspectors before you let them into the pharmacy, and they should be patiently expecting you to do this. If you usually leave safes and stuff open that shouldn’t be definitely do a quick run around spot check before letting them in but by the time they show up it’s too late to start sweeping actual problems under the rug.
Never give anyone over the phone claiming to be board inspectors or “from the board” any information at all. This is an increasingly common scam vector.
How do I deal with unreasonable demands from managers and metrics? What the holy hell is NPS?
I don’t necessarily have a lot of good advice here because this is a problem I mostly wasn’t able to solve either. A lot of states are trying to bar chains from directly holding their pharmacy employees to metrics but it’s reasonable to expect these to be temporary band-aid solutions that will eventually be overcome by companies finding alternative ways to do the same thing. No amount of ranting about Goodhart’s law or principal agent problems is going to stop companies from using abstract metrics packages sold to them by Strategic Solutions™®© firms to attempt to divine ground-level success instead of looking at object level numbers and problems.
Best I can really tell you is to just smile, nod along, and don’t make promises. They can make the metrics imply just about any situation they want, so don’t stress over it too much (it’s how the chains now all weasel out of giving everyone raises any more). If they’re trying to roast you over some number not being what they want ask them to tell you what specific things they want you to do differently and see what you get. Sometimes they don’t even know and then it’s fun to watch them squirm a little bit. Sometimes you get eye-rollingly-bad boilerplate stuff like “do better teamwork”.
I would suggest that you should never be actually trying to hit metric targets because it only encourages them to continually set newer, harder targets, but again I may not be the best source of advice here.
NPS is kind of a fun topic to dig into. NPS is short for Net Promoter Score, it’s why a lot of big corporations have weird hard-ons for customer surveys. It’s designed to measure customer loyalty (note: not customer satisfaction). If you’ve ever seen one of those customer surveys the relevant question is some variation of “would you recommend this company/product/service to friends/family/colleagues?” There’s usually a numerical rating that’s supposed to be used to calculate a score using a theoretically-Scientifically-Validated score but in my experience it’s been easy to deduce that the classically validated methodologies for NPS aren’t being adhered to by companies hounding their employees on it, nor are they setting realistic goals.
NPS ends up being not too difficult to Goodhart, just collect receipts from customers who don’t want them and then hand those around to your coworkers/friends/family to use the survey codes on their phone.
Why do they keep cutting our hours/why are they paying me almost a dollar per minute to bag groceries instead of hiring more techs and clerks?
I honestly have no clue but if you ever find out PLEASE tell me. Supposedly there’s complicated arcane galaxy brain formulas used to set these but there’s zero transparency and empirically it’s pretty bullshit. First chain I was at had periods of time that we had 3 staff pharmacists; we’d end up in goofy situations where we would have hours allotments for a day with 3 pharmacists and only 2 technicians. We found out at some point that this was almost certainly because our district manager had family who picked up from our pharmacy.
I got offered a pharmacy manager position, what do I do?
My condolences, but again this kind of depends on your risk tolerance. I hear the pay bump isn’t even that much, especially commensurate with everything new your license is on the line for.
Personally, I would never accept a pharmacy manager or pharmacist in charge position without knowing the pharmacy and its staff very well over a decent period of time, but that’s evidently just me.
I, uh, got forced into a pharmacy manager position against my will/without anyone telling me, what do I do?
So, definitely, people need to be aware that this is a thing that can happen. It’s not even something unique to big corporate chains, I’ve heard firsthand from state employees in California that it has happened for problem pharmacies within living memory.
Check your local state law, a lot of states allow you to manually opt out of being designated pharmacist in charge with the board of pharmacy, which is probably why companies will try to do this on the down low. I don’t exactly know what happens to your job in this situation but this is already probably a sign you should start looking elsewhere.
Should I consider going to pharmacy school?
No. As of now I would only recommend pursuing a PharmD if you have either a specific intractable interest in medication or pharmacology or have some kind of family business or tradition around the profession. Or if it’s one of the best options given your specific local/financial circumstances, which is more or less how I got here (but I also didn’t exactly look around very hard).
No amount of professional beaming about how pharmacy is “the number one most trusted healthcare profession” changes the fact that neither the general public nor the broader healthcare profession has demonstrable respect for pharmacy. Watch how both fight any effort to let us prescribe.
If you’re considering pharmacy there’s multiple pretty comparable alternatives in healthcare if you’d prefer not to simply go to med school. Consider gunning for physician assistant or nurse practitioner instead, you might be surprised to find out that both require around the same amount (or less) of schooling, are able to more easily obtain prescription authority, and don’t have to take licensing exams.
Uh oh, uh, so let’s say, hypothetically, that I’m already in pharmacy school, what do I do now?
I guess it depends on how far in you are, but I wouldn’t say I recommend against pharmacy school enough to suggest you should immediately drop out. Definitely try to have a much more realistic outlook for your post-graduation options than I did. I had one classmate who finished his PharmD and was in med school the next semester, so there’s that option, I guess.
Is there really a pharmacist shortage?
Ehhhhhhhhhhh maybe? It looks like the equilibrium is very slightly weighted towards there being more new grads than new jobs, but this is complicated slightly depending on how NAPLEX and MPJE pass rates translate new grads into new pharmacists in a way that might be tilting it closer to more new jobs than new pharmacists. I recall a while back seeing a press release from some professional org saying that there were more new jobs than new pharmacists year over year, being outraged, but then being unable to find information proving them wrong.
Looking for numbers now, the American Association of Colleges of Pharmacy says there was 14320 new PharmDs in 2019-2020. The U.S. Bureau of Labor Statistics says job growth is around 2% per year, projecting 13600 openings per year. With no indication about job quality I’m vaguely concerned the majority of those new openings are bottom-of-the-barrel chain ones.
Eyeballing statistics on first-time pass rates from the NABP, it looks like the first-time pass rate (for each of the NAPLEX and MPJE) is around 80%, which would translate the 2019-2020 grad numbers to 11465 new licensed pharmacists. This is definitely not a correct number because I’m just taking an 80% slice of the new grads since I’m not deft enough with statistics to account for people potentially failing both exams. Also, presumably, some majority chunk of that fail rate will go on to take the exams again and pass, possibly in enough numbers to get fairly close to the 13600 openings/year.
Don’t buy the recent hype from chains about there being severe enough shortages to force them to cut operating hours. Even APhA is quick to point out that no there’s only a shortage of pharmacists willing to tolerate chain working conditions.
Okay, I’ve had enough of this, how do I get away from retail?
It’s going to be an uphill battle but stick with it. This is especially true if you’re trying to get out of retail completely; this will probably be a little bit less of a slog if you don’t mind doing non-chain retail.
Having more time on your resume will help before you jump ship and the biggest hurdle is going to be getting that first non-chain job. If you don’t have pre-existing contacts, staffing agencies can help with your first steps. Look for per diem positions with hospitals or their attached outpatient pharmacies since they tend to be a little more forgiving with qualifications but despite what they’ll tell you these aren’t a guaranteed in with them for future full-time jobs.
There’s honestly not a whole lot I can say here because I can’t rightly say I’ve made a secure escape from retail myself, so good luck I guess. I can also recommend Grant Harting’s How to Escape Retail Pharmacy Hell having skimmed it a few times.
Postscript
So there’s a lot of words about retail pharmacy. There’s a lot of angst within the profession about how the public doesn’t have much of a grasp of what we do and I hope this is bridging some of that in ways that haven’t been covered before. Keep in mind: having lots of patience and expecting the worst is generally the best approach, and most of us really do want to help you even if we’re really obtuse about it and will only do it by fax.