USA - Filling a prescription without insurance is illegal??

[staples]

Hi,

I have been prescribed to zolpidem (Ambien) 10mg long-term, sometimes switching to Ambien CR (which is only available as name brand and thus pretty expensive) for various reasons.

A little over a year ago I took a trip to California with my girlfriend's family. Before leaving, I was never entirely clear on the details of where we would be, or if I would be able to visit a pharmacy there (it turns out I wouldn't have been able to). However, I would have run out of my medication during the vacation.

I visited the pharmacy the day before my flight and explained my situation to the pharmacist. Apparently with my insurance, I am allowed a quota of vacation overrides (the pharmacist used a specific term, I don't remember what it was), and apparently that quota is 1 (per at least several years?) but I had already used that one when I had traveled to Minnesota on business a couple years earlier.

Now this is the root of my recent confusion: The pharmacist gave me the option of bypassing my insurance and simply paying out of pocket to have my prescription filled. Thankfully, it was the generic instant-release version and so I could afford to do this.

A few months ago I asked my doctor to switch to Ambien CR. I left the last 10-11 pills at my friend's apartment after visiting; he lives about 80 miles away. I arrived back to my home around midnight before noticing that I was missing my medication, and I justified paying for 10 pills (which was very expensive, I wish I had done 5!) rather than making the trip to and from my friend's apartment, making him stay up late for me. The pharmacist let me bypass insurance without issue.

Last month, more than half way through my prescription, I visited my mother and accidentally left my prescription at her house. My mom sold her house and is in the process of moving into a new one, and so my prescription is in storage somewhere. So I visited the pharmacy and asked if I could purchase 5 of my refill, since I knew insurance would not cover it yet. The pharmacist did this for me.

3 days later it was clear that I still wouldn't be able to get my prescription out of storage very soon, so I returned to the pharmacy to ask if I could purchase an additional 5; I usually refill when I have 1 or 2 pills left just to be safe, I thought this was typical. This time, the same pharmacist was a little reluctant, she said I should have 2 pills left. I told her "yes." I'm not sure what her reasoning was, but after typing some information into the pharmacy computer, I'm guessing she noticed that I still would not be able to fill my prescription after running out, so she filled the 5 pills for me.

While I was paying, the pharmacist started scolding me! I was left speechless! She made it clear that this was the last time she would let me pay for my prescription without my insurance; she said many times that doing this is illegal! All I could manage to say was "all right" or "okay" because suddenly I was overcome with confusion and had way too many questions than I wanted to ask.

How can that be illegal? What if I didn't have insurance?? How is it that I learned about this option from a pharmacist? How is it that, with all the bureaucracy involved in dispensing a controlled substance, any pharmacist was able to let me bypass insurance in the first place if it were illegal? Wouldn't the implication of what that pharmacist told me be that only people who have health insurance can legally be prescribed to Ambien CR? That can't be right!

I just saw a neurologist last night about my sleeping troubles and she wanted me to try Temazepam (Restoril); I was passive-aggressively hoping that the same pharmacist would be working when I went to fill the new prescription (especially since she wrote me 5 refills, which I understand to be the maximum). I was kind of hoping she would be suspicious enough to even call the prescribing doctor to find out that it wasn't just some random general practice doctor who I might've fooled into giving me a prescription, but a specialist; I guess I imagine that she's assuming I'm abusing my medications, and this would make her see that I do in fact need them, and I'm not bullshitting her when I ask to bypass insurance. Unfortunately she wasn't working last night.

Anyway, can any lawyers, anyone studying law, or anyone who just happens to be familiar with the relevant laws here clarify things for me?

Thanks!

[fuzelogic]

SWIM read SWIY post and is surprised at how many times SWIY has misplaced or forgot the medicine. They make travel kits for taking medicine day by day. SWIM would hope they could manage their medicine alittle bit better especially if it's needed?


1. BTW, SWIM understands that shit happens to all SWIMMERS on here, so to answer SWIY questions. Obviously the pharmacist can see that SWIY has been prescribed a medicine in the past. People forget the medicine sometimes and need a couple extra pills until they can get a new script.

But, now SWIY has a record that shows mutliple times when they forgot or misplaced the medicine. Now, pharmacist is curious how many times SWIY is going to fuck up and misplace the medicine and a red-flag is starting to appear on SWIY EVEN if it's a legit mistake cause the pharmacist doesn't know SWIY or care what the excuse is because they have heard ALOT of them.

2. A pharmacist would love for SWIY to pay cash for SWIY medication as long as the patient has REFILLS. Plus, 5 pills here and 5 pills there can start to add up to whole refills before the prescription is supposed to be refilled. The problem is they can't keep giving SWIY more pills to hold SWIY over on a prescription if it's out of REFILLS.

3. SWIY is putting the pharmacist in a bind because IF they were to be audited by the state, they are going to be questioning them about the prescriptions they filled for people like SWIY. Now, by SWIY missing placing the pills and the pharmicist helping SWIY out multiple times could lead to them being fined or lose their license. For example, should the DR be sued for giving Micheal Jackson the medication that he wanted? It becomes a grey area in the leagl system in which the supposed good guy gets screwed.

4. As SWIY stated the brand is expensive to fill. The insurance company could decide to NOT PAY the pharmacy for the medicine due to filling it too early or for whatever reason. Now, Mrs. Pharmacist is stuck with SWIY cost of pills because they wanted to help SWIY out!

[staples]

Originally Posted by fuzelogic

SWIM read SWIY post and is surprised at how many times SWIY has misplaced or forgot the medicine. They make travel kits for taking medicine day by day. SWIM would hope they could manage their medicine alittle bit better especially if it's needed?

Twice in four years? Only ever in the last few months? Sounds like situational anxiety to me...

Originally Posted by fuzelogic

1. BTW, SWIM understands that shit happens to all SWIMMERS on here, so to answer SWIY questions. Obviously the pharmacist can see that SWIY has been prescribed a medicine in the past. People forget the medicine sometimes and need a couple extra pills until they can get a new script.

But, now SWIY has a record that shows mutliple times when they forgot or misplaced the medicine. Now, pharmacist is curious how many times SWIY is going to fuck up and misplace the medicine and a red-flag is starting to appear on SWIY EVEN if it's a legit mistake cause the pharmacist doesn't know SWIY or care what the excuse is because they have heard ALOT of them.

I understand this much; I was wondering if there were perhaps a certain piece of legislature or similar that someone could point me to, though. The law can't be this fuzzy, can it?

Originally Posted by fuzelogic

2. A pharmacist would love for SWIY to pay cash for SWIY medication as long as the patient has REFILLS. Plus, 5 pills here and 5 pills there can start to add up to whole refills before the prescription is supposed to be refilled. The problem is they can't keep giving SWIY more pills to hold SWIY over on a prescription if it's out of REFILLS.

I was more surprised at the fact that she let me fill (and, I didn't mention this, she advised that I fill) 10 pills the first time, then the second time, she asked if I wanted 10, but I said I thought 5 should do, yet when I was wrong and returned for an additional 5, she practically yelled at me! I do not understand what you mean regarding running out of refills, my prescription called for a refill of 30 pills, I was asking to fill up to 10 of them earlier than my insurance would pay for.

Originally Posted by fuzelogic

3. SWIY is putting the pharmacist in a bind because IF they were to be audited by the state, they are going to be questioning them about the prescriptions they filled for people like SWIY. Now, by SWIY missing placing the pills and the pharmicist helping SWIY out multiple times could lead to them being fined or lose their license. For example, should the DR be sued for giving Micheal Jackson the medication that he wanted? It becomes a grey area in the leagl system in which the supposed good guy gets screwed.

I don't understand; I was not getting any additional pills beyond the amount to which I was legally prescribed. Had I not had insurance in the first place, then there would've never been the problem of insurance refusing to fill my medication early, right? It's not like I was asking for pills to hold me over until I could get another prescription from my doctor, I don't understand what is illegal here? I've seen advertisements about saving money on prescriptions by having 3 months-worth filled at a time...

Originally Posted by fuzelogic

4. As SWIY stated the brand is expensive to fill. The insurance company could decide to NOT PAY the pharmacy for the medicine due to filling it too early or for whatever reason. Now, Mrs. Pharmacist is stuck with SWIY cost of pills because they wanted to help SWIY out!

What are you talking about? I mean, yes, this is the entire problem here: my insurance did not want to pay so early. I am the one stuck with the payment, and in the cases above I have justified paying that amount, the pharmacist does not incur any fees...

[fuzelogic]

If a DR says SWIY need an operation is SWIY going to have it without a 2nd opinion first? Just because their a DR doesn't always mean they are correct? Not, all pharmacist are going to be the same and some could just be a dick anyways.



Partial Filling of Prescriptions

A pharmacist may partially fill a prescription for controlled substances. If the remainder is not dispensed to the patient within the following 72 hours, the prescription is void and must be rewritten in order for the patient to get the remainder. Partial refills of Schedule III, IV, and V controlled substance prescriptions are permissible under federal regulations provided that each partial filling is dispensed and recorded in the same manner as a refilling (ie, date refilled, amount dispensed, initials of dispensing pharmacist, etc), the total quantity dispensed in all partial fillings does not exceed the total quantity prescribed, and no dispensing occurs after 6 months past the date of issue" (21 CFR Section 1306.13).

Yes, it does sound like that or that person could be just having a bad day? When SWIM read SWIY post it seem like it all happen within 3 months time period.

[staples]

Originally Posted by fuzelogic

If a DR says SWIY need an operation is SWIY going to have it without a 2nd opinion first? Just because their a DR doesn't always mean they are correct? Not, all pharmacist are going to be the same and some could just be a dick anyways.

What does my doctor's opinion have to do with anything? For what it's worth, I've seen 4 or so doctors in total, switching my treatment from one to the other, and then seeing specialists on top of that. It is none of the pharmacist's business why I need any sort of medication. Regardless of the pharmacist's personality, my options as far as filling my legally-prescribed medications should not change.

Originally Posted by fuzelogic

Partial Filling of Prescriptions

A pharmacist may partially fill a prescription for controlled substances. If the remainder is not dispensed to the patient within the following 72 hours, the prescription is void and must be rewritten in order for the patient to get the remainder. Partial refills of Schedule III, IV, and V controlled substance prescriptions are permissible under federal regulations provided that each partial filling is dispensed and recorded in the same manner as a refilling (ie, date refilled, amount dispensed, initials of dispensing pharmacist, etc), the total quantity dispensed in all partial fillings does not exceed the total quantity prescribed, and no dispensing occurs after 6 months past the date of issue" (21 CFR Section 1306.13).

Aha! Exactly what I was looking for, so nothing that I've said in my original post describes anyone conducting an illegal activity.

Originally Posted by fuzelogic

Yes, it does sound like that or that person could be just having a bad day? When SWIM read SWIY post it seem like it all happen within 3 months time period.

Ah, the two misplacements of medications did occur in the last few months, but the early refills for traveling to California or Minnesota happened 1.5 and just under 4 years ago, respectively. I just mentioned them to explain how I learned that I could bypass my insurance. I suppose you're probably right and it must've been that the pharmacist was simply having a bad day, hmm.

Thanks!

[chibi curmudgeon]

Originally Posted by staples

I was more surprised at the fact that she let me fill (and, I didn't mention this, she advised that I fill) 10 pills the first time, then the second time, she asked if I wanted 10, but I said I thought 5 should do, yet when I was wrong and returned for an additional 5, she practically yelled at me! I do not understand what you mean regarding running out of refills, my prescription called for a refill of 30 pills, I was asking to fill up to 10 of them earlier than my insurance would pay for.

The problem wasn't so much that you wanted a total of 10, the problem was that you were coming back for another 5. Unless I'm mistaken (I got a C+ in pharmacy law) that's a whole new refill, making 2 of them before your insurance would pay. She advised you to get 10 in case you'd end up needing that many.

I don't understand; I was not getting any additional pills beyond the amount to which I was legally prescribed. Had I not had insurance in the first place, then there would've never been the problem of insurance refusing to fill my medication early, right?

True, but this is more about the lack of script. What fuzelogic was talking about is that if you get an early refill that you've been paying cash for anyway, that's one thing. But if you get early refills of a controlled substance that you usually have insurance for, and pay cash for them...you see why the DEA might look cockeyed at this? The pharmacist who sold you the substance would be in far more trouble than you would.

I've seen advertisements about saving money on prescriptions by having 3 months-worth filled at a time...

For controlled substances, that's a little different, since prescribers can't write a script with 2 refills. My roommate takes hydrocodone for menstrual cramps from hell; instead of being given 10 to be taken over 3 days, she'll be given 30 to be taken over 9 days. Presumably all in one month, but since she only needs them for 3 days, they'll last 3 months.
I'm not sure what the law is for this, if you could get around it by prescribing Ambien 3 times a day (with the patient understanding that it's only to be taken once a day). Especially since Ambien 3 times a day is obviously ridiculous. The law might also vary by state.

[staples]

Originally Posted by chibi curmudgeon

The problem wasn't so much that you wanted a total of 10, the problem was that you were coming back for another 5. Unless I'm mistaken (I got a C+ in pharmacy law) that's a whole new refill, making 2 of them before your insurance would pay. She advised you to get 10 in case you'd end up needing that many.

What is the significance of 2 refills before insurance would pay? The legislature quoted above doesn't seem to make any such provisions...

Originally Posted by chibi curmudgeon

True, but this is more about the lack of script. What fuzelogic was talking about is that if you get an early refill that you've been paying cash for anyway, that's one thing. But if you get early refills of a controlled substance that you usually have insurance for, and pay cash for them...you see why the DEA might look cockeyed at this? The pharmacist who sold you the substance would be in far more trouble than you would.

lack of script?? No, I had a prescription written with 1 refill, the first time I filled it, I had one refill remaining, but circumstances lead me to ask for a partial refill before insurance was willing to pay. And what's with the cash distinction? With insurance, I do have a co-pay... and in both cases (when using or when bypassing insurance) I charge to my credit card... I do not see why the DEA might find this peculiar.

Originally Posted by chibi curmudgeon

For controlled substances, that's a little different, since prescribers can't write a script with 2 refills.

As I understand it, prescribers cannot authorize any refills on a schedule II substance, otherwise they can authorize up to 5 refills.

[chibi curmudgeon]

Originally Posted by staples

What is the significance of 2 refills before insurance would pay? The legislature quoted above doesn't seem to make any such provisions...

That bit was about partially filling an original. i.e.:

Guy goes to doctor, gets brand new script for 30 tabs of a controlled substance. Guy goes to pharmacy, and for whatever reason only wants 10 tabs. Pharmacy can fill just 10, but guy must come back for 20 within 72 hours.
Guy does not come back within 72 hours. Script is invalid. 10 is as many as he'll get. He needs another script to get more.

In your case, the problem was that you got a partial fill, and then ANOTHER partial fill. Both early, as far as insurance is concerned. By "paying cash," that just means you're not using insurance--you're paying the pharmacy's full price for the drug, they give you drug, you give them money, and that's it. This is different because you're not bound by any insurance company's (or Medicaid's) rules about how much drug one person can have within a specified period of time. People might choose to pay cash even if they have insurance so they can get more drugs than insurance thinks they need.

e.g., someone who's addicted to a drug, and goes to different doctors to get multiple scripts. If they go to different pharmacies, and don't let their insurance provider in on what they're getting, no one's the wiser. See why the whole cash-for-early-refills thing is suspect?

Not saying that no one ever has a legitimate reason, but pharmacists put up with a lot of this doctor-shopping crap, and if they're too lenient the DEA might think they're in on the whole thing.

As I understand it, prescribers cannot authorize any refills on a schedule II substance, otherwise they can authorize up to 5 refills.

I think this varies by state.