Intranasal midazolam and diazepam are now commercially available. You may notice increased demand from your prescribers for these products because patients may feel that the nasal formulation is less intrusive in comparison to rectal diazepam.
Also many providers may choose to use these products instead of diazepam rectal gel because of administration concerns… as the nasal formulations are deemed easier to administer by caregivers and/or school nurses.
Pharmacists, be careful when dispensing the 15mg and 20mg intranasal diazepam products — please note that each intranasal dose is 7.5mg per nostril for the 15mg product and 10mg per nostril for the 20mg product. This can be somewhat confusing initially as the 5mg and 10mg products do not follow the same pattern of being one-half of the listed dose per nostril (please read package insert to better understand).
Lastly, please refer to the package inserts of each product to ensure dosing is appropriate. In particular for pediatric patients. Please ensure that your prescribers directions are accurate, and that your patients and caregivers understand how to administer the product. Access to these products may be slower than normal due to the pandemic; thus make sure your patients know which pharmacies in their community dispense the product, so that they can make informed decisions prior to and after discharge from the hospital.
***Note: Please refer to the FDA package inserts, your pharmacy’s drug information resources, your state board of pharmacy policies, and your clinical judgement prior to dispensing. And if you still have further questions please never hesitate to contact the drug manufacturer. Information in this blog post does not substitute for your own clinical judgement. ***
***Patients, please discuss all medical and pharmacy options with your physician. This blog post does not substitute for an individual one on one consultation with your physician. In all cases of emergency please always call 911***
I will upload my personal lecture audio under this post throughout our 8 weeks together.
The lesson manual includes content covering 8 lessons, quizzes, previous final exams, and information pertaining to how to conduct yourself on externship. Please use this manual as your guide to complete this course. It will take both in class and out of class studying to complete each of the 8 lessons. Each lesson should take you at least 4 hours to cover.
Please refer back to the lessons as needed.
I will not print lessons, it is up to you to follow the material accordingly. The links are below.
Classroom to be used: Ethel Hall Building – Room 201
Time: 9:00am – 10:30am
PDF’s for download:
May 1, 2019 Lecture on Lesson 1 :
May 7, 2019 Lecture on Lesson 2:
May 14, 2019 Quiz 1:
Quiz 1 will be given on May 14, 2019. You will have 45 minutes to complete the quiz (9am – 945am). There will be a brief break and then a review of the quiz by your instructor for the remainder of the class.
Quiz 2 for May 15, 2019 will be rescheduled. We will instead cover Lesson 3 and go into more depth review of the material thus far. We will also have a lab to get hands on knowledge of the material covered.
Homework — please continue to keep studying the top 200 drugs from your text. You should now be memorizing pages 4, 5, and 6 of the top 200 from your workbook.
The class average for quiz 1 was 68%.
May 15, 2019
May 15, 2019 Audio Part 1:
May 15, 2019 Audio Part 2:
Quiz 2 will be next Wednesday May 22, 2019 over the top 200. Use previous quizzes from last year to study for Quiz 2. There will be 75 questions on quiz 2 and you will have 1 hour to complete the quiz.
To receive extra credit on quiz 2, please look over the top 200 and type up a summary on 25 drugs of your choice. For each medication — list the brand name of the drug, the generic name of the drug, the classification of the drug, and the body part the drug acts on.
For example… ProAir HFA is an inhaler and is classified as a respiratory agent, the generic name is Albuterol HFA and the body part that the drug acts on is the lungs. The drug acts in a manner to open the airways so that a person can breath normally.
If you type up 25 drugs and do it as I’ve asked you, you can receive up to 25 points extra credit on quiz 2. Remember, it must be typed!!! And you must turn this in on Tuesday May 21, 2019 to receive credit.
Please continue to look over the externship material. Sign the final page of the agreement, informing me that you’re committed to a 40 hour externship, and please talk to DHR and/or JCCEO to inform them of your intentions to become a registered pharmacy technician — you need to be registered prior to going on externship. This costs $103.
Tuesday May 21, 2019 we reviewed Lesson 3 and began covering Lesson 4. We finished the first problem in Lesson 5. Please work on the second question in Lesson 5 and read Chapter 6.
Audio from Tuesday May 21, 2019:
Wednesday May 22, 2019 the second quiz for this session was administered.
After taking into account the 25 point bonus — the class average for quiz 2 was 77.8%
A review of Chapter 6 continued during this lecture post quiz. Please continue to work on Chapter 6 and review Lesson 1-Lesson 5 for class next week.
Tuesday May 28, 2019 the third quiz was administered by Janiece. All those present received a 100% on the quiz.
Wednesday May 29, 2019 we completed Lesson 7 — please continue to review Lesson 7. We reviewed Lesson 5.
Lecture Audio May 29, 2019:
For Quiz 4 prepare in this way:
- Memorize section A conversions from Lesson 5
- Be prepared to answer multiple choice questions that relate to prescription examples Baby Girl Roberts, Janet Jackson, and Henry Ford from Lesson 5.
- Lastly, review the Alligation Hydrocortisone example that can be found on page 184 in your text. This example will be used for your quiz.
June 4, 2019 the quiz will be 25 questions. We will then review Quiz 4 –> proceed to a lab on compounding –> and review Lesson 8.
Please review your syllabus, our time together is nearing the end.
June 4 — Quiz 4 and practical compounding lab
June 18 — Final Exam
June 19 — Review of the Final Exam administered on the 18th and Final Grades
- Please continue to study, work diligently on your pharmacy technician registration, work on your resume’, and begin submitting applications to local pharmacies
- If you find a job as a pharmacy technician or as a pharmacy cashier prior to externship, you will not have to complete an externship.
50 point extra credit!!!!!!
Write two paragraphs describing each lesson that we have completed thus far. We have completed Lessons 1, 2, 3, 4, 5, 7.
Give 2 examples from each lesson and why each example is important in becoming a pharmacy technician.
For example in your paragraph you describe Pharmacy Technician Registration in the State of Alabama…
In Lesson 1 we discussed how to become registered as a pharmacy technician. It is important that pharmacy technicians know that in the State of Alabama we register by using albop.com. The annual fee is $103 with renewals occurring in odd years.
Remember 2 examples from each lesson, each example should be 1 paragraph in length. This must be typed. 12 point font. Times New Roman. Double spaced.
June 4 2019
June 4 2019 Audio —
If anytime remains we will begin covering Lesson 8.
Externships will be emailed out this Friday June 8, 2019. It is your responsibility to contact the Pharmacy Managers/Lead Technicians to setup days that you can complete your 40 hours of training. You will have 3 weeks to complete training. You are exempt from externship if you have found a job in Pharmacy.
June 11 2019 — Janiece will cover Lesson 8/Discuss Externship
June 12 2019 — Practice Final Examination/Discuss Externship
Link to practice final exam — please use your books and internet to study
The final exam will be 60 questions, you will have the full class session to complete.
Topics to cover: pharmacy workflow, prescription benefit card, math conversions, sig codes, pharmacy law, brand/genetics, and pharmacy math!
June 18 2019 — Final Exam/Questions/Discuss Externship — we need copies of your pharmacy tech registrations!
June 19 2019 — Final Grades/Review Final Exam/Questions/Discuss Externship
October is American Pharmacists Month.
This Profile is truly a reflection of the commonality in our life’s story that first began in a dormitory nearly 20 years ago. I met Donaye circa fall 2001 while living in Pittman Hall at Samford University.
Pittman Hall was our home away from home. A place where we would study, sleep, eat, and bond over ping-pong and television. Some of the men that I would meet during those days would later become our future leaders in law, medicine, pharmacy, dentistry, business, and public health.
We lived our best lives in a chasm between the “Bubble” and being outside the “Gates.” While we made jokes of our existence living in the “Bubble” by acting as though we so desperately needed to escape; we all silently understood that we loved and respected the safety of our campus. The safety, the tranquility, and the ease by which we maneuvered in this “Bubble” allowed us to grow up and learn from both our successes and our failures, our ups and our downs, our hopes and our fears.
After a long day, we would swipe our ID badges to have access to the CAF where we would eat, sit, and listen and learn from each other. We learned life lessons over those meals; we needed those lessons and that support from one another to become the men we are today. Furthermore, it was because of our days in the “Bubble” that we were able to have a real opportunity to learn from our mistakes in a safe environment.
We laughed, yelled, cried, and prayed with one another. We spent many late nights studying and fighting sleep. We broke bread together, or rather broke onion rings together at our favorite hang out The Purple Onion. And then one day we walked across a stage and shook hands with the President of the University, took pictures, and became official graduates of an institution of higher education. We came in as boys and left to begin our journey as young men. We hugged each other, said we would keep in touch, and departed from each others presence to attempt to fulfill the mission that God had given each one of us. We all worked hard to make it; working to achieve our full potential to become the men that God created… men that could successfully take care of family and self.
After Donaye graduated from college, he attended Physical Therapy school in Georgia. I thought I wouldn’t see him on campus again, except for a few football games here and there. But sometime in the fall of 2002 during my Sophomore year of college that all changed.
Donaye entered the classroom for my General Chemistry II course with books, and I looked at him and said, “dude what are you doing in here…I thought you were doing Physical Therapy school?”
His response, “I changed my mind, I’m going to Pharmacy School.”
Little did we know — our individual journeys would continue to cross paths as we took a whirlwind adventure towards completing our goals, and reaching our final destinations as “First Generation PharmDs“. In that Chemistry class I watched Donaye meet the love of his life, a year later I watched him enter Pharmacy School, and four years later he would graduate.
How many actively practicing Pharmacists do you know are Hip-Hop artists? Donaye Blake, PharmD has produced 4 albums and is currently in the studio working on album number five. But it’s his album “The Sequel” that most inspired me in my own personal pursuit towards becoming a Pharmacist. In the song entitled “Guess Who“, I felt his pride, determination, and energy on his impending accomplishment of earning a PharmD when he rapped the following words…
“Haters hate the fact, that I’m so laid back, PharmD slash Rap, imma get that“. — Dab Haskal — lyrics from song “Guess Who” album, The Sequel
I would enter Pharmacy School in 2008 one year after he graduated from Pharmacy School in May 2007. Donaye, now a Retail Pharmacist with Walgreens helped me earn my first job in Pharmacy by recommending me to the Pharmacy Manager Joe Randall, PharmD. I’m thankful for that opportunity as I began to learn about my profession in a community pharmacy.
Fast forward and Donaye has been a practicing Pharmacist for 11 years. He’s worked as a Retail Community Pharmacist and he now serves in the role of a 7 on 7 off Staff Hospital Pharmacist. I’m thankful to know him because just seeing him achieve his goals, helped me to believe that I could do the same.
Lastly, but most importantly, Donaye Blake, PharmD is a devoted husband and a wonderful father to two beautiful daughters.
Once again, I’m very thankful for Donaye taking the time to reflect and respond to this set of questions. He has never been shy about expressing his personal truths. Thus, readers, please take into consideration his perspective on the Life of a Pharmacist. He offers a diverse perspective that both Pharmacy peers and laypersons can take into consideration in understanding our diverse perspective on describing the pressures of attending Pharmacy School and the pressures of being an actively practicing Pharmacist.
Sam: When did you graduate Pharmacy School?
Sam: Bachelors Degree?
Donaye: Exercise Science
Donaye: No. I was ready to get paid so I could give it all to Sallie Mae
Sam: Can you tell me about your career — what jobs you’ve had — positions and titles that you’ve held — please don’t be modest
Donaye: Because the pharmacist job market was far less saturated than today’s, I took a two and a half month break after graduation to travel, relax and study. After finally sitting for and passing the boards, I immediately started at Walgreens as a floating pharmacist between two Birmingham stores. After 3 years of floating, I accepted a 7 on 7 off overnight position which was the best decision of my professional life. After seven years of overnights and relocating my family to Tennessee, I was offered a position at a leading hospital in Nashville as a 7 on 7 off day shift staff pharmacist.
Sam: A lot of folks may not know that you’ve had an influence on me considering a career in pharmacy. I remember seeing you around campus in 2001 and watching you go through the phase of considering a career in physical therapy and then transitioning your career towards a pursuit in pharmacy. How did you realize that pharmacy was the right fit for you?
Donaye: While in Physical Therapy School at North Georgia College, we had a guest speaker from Mercer’s pharmacy program. He was giving a lecture about loading dose and I was so absolutely intrigued that I actually immediately withdrew from the physical therapy program to return to Samford University in order to satisfy prerequisites for McWhorter School of Pharmacy.
Sam: We both graduated from the Exercise Science Sports Medicine Department when we were in undergrad. Has that undergraduate background had an effect on your practice as a Pharmacist? If so, in what ways do you incorporate that foundation of knowledge?
Donaye: In my opinion, Samford University’s Exercise Science program is one of the most thorough programs in the country. That foundation of knowledge has been paramount in assisting in patient counseling and recommendations as patient questions aren’t always exclusively about drugs. Understanding physiology and anatomy is sometimes extremely helpful for productive patient consultations.
Sam: I know that you have a passion for music – especially hip hop music. You’ve released multiple albums under the moniker “Dab Haskal” – how have you been able to balance music with your professional life as a Pharmacist?
Donaye: I’ve always had the belief that if people really want to do something, they’ll find time to do it. Music is my opportunity to vent about social and political frustrations, but in a creative and inspiring space. It’s as much a part of my identity as my last name. I’m currently working on a project called ‘Therapy.’ This will be album number five.
Sam: Have you ever performed live with a band? Do you think some of your patients would suspect that you’ve released multiple Hip-Hop albums?
Donaye: Early on, I did several live shows including a charity event at Samford University (Kickin’ It for Kidz). No. My being a hip/hop artist appears to be a foreign concept to patients and co-workers alike…until they hear a sample. I prefer the element of surprise
Sam: Life as a Pharmacist can be very stressful. We live a life where there’s no room for error. How do you balance this professional life with being a family man?
Donaye: As a young Pharmacist, I didn’t require much sleep so finding time for professional and family life was no problem. However, now that kids have entered the picture, priorities have changed. Fortunately, my 7 on 7 off schedule allows me to spend more time with the family than the average full-time pharmacist.
Sam: What advice would you give to pharmacy students and actively practicing Pharmacists on how to maintain an appropriate work/home balance?
Donaye: I would advise young Pharmacists to work as hard and as much as they can early to pay off all debt so later they can benefit from having such a wonderful salary. No debt provides options and less desperation during times of transition and/or professional hardships.
Sam: Based on current USA data published from https://datausa.io/profile/soc/291051/ black people make up 7% of actively practicing Pharmacists. Thus, me and you are part of the 7 percent. What words of encouragement would you give young black kids looking at you thinking it would be cool to become a Pharmacist, yet uncertain if they could overcome potential life obstacles to make it?
Donaye: I would encourage young black kids to drown out negativity and believe in themselves. There’s nothing special or exceptional about that 7% of black pharmacists other than them taking interest in the pharmaceutical field and pursuing it to completion. I’m of the belief that anybody of sound mind & body can accomplish just about any endeavor with enough hard work and desire to achieve. Today, the only obstacle is mental!
Sam: Describe a day in your life as a practicing Pharmacist. What are some of the things the public doesn’t always understand you’re dealing with in making appropriate pharmaceutical care decisions?
Donaye: In the retail setting, life as a Pharmacist (and technician) was just short of chaos. In my 11 year experience with retail, much of it was spent understaffed with impossible goals set for my team by upper management. We’d have to juggle phones ringing nonstop, high script counts and the drive thru buzzing constantly all while being short-handed and exhausted. So yes, making appropriate pharmaceutical care decisions was a daily challenge, but one that most retail pharmacists and technicians did/do flawlessly.
Sam: How must Pharmacists improve their communication with the public so that the art and science of pharmacy can be more understood?
Donaye: In the retail setting, I think pharmacists have done an excellent job at communicating with the public. I think the biggest obstacle is actually finding time to speak with patients with all the other responsibilities and handicaps hindering that most important task (interpersonal communication)
Sam: Why has a Pharmacy Sitcom never been created? If it were created should it be in a retail pharmacy or in a hospital pharmacy? I vote retail but that may cause a bit of division in our community 😉
Donaye: It’s interesting that you asked. A good friend approached me about a possible reality show based on my overnight pharmacy retail life. Apparently, he read one of my numerous “Midnight Madness Chronicles” on Facebook and was highly amused. The idea quickly fizzled out because I didn’t think Walgreens would allow cameras and video equipment in the pharmacy due to HIPAA regulations. I think retail pharmacy would be an ideal setting for a pharmacy sitcom.
Sam: You’ve had a passion for finance for years. I remember you talking about Dave Ramsey books and how to save and pay off debt. What would be your advice for pharmacy students and Pharmacists struggling with student loan debt?
Donaye: I graduated with 204k in student loan debt. My advice would be to work hard early and often to chip away as soon as possible. Do not let it linger. Do not buy a house and/or car after graduation. Do not take advice from other broke pharmacy students with hundreds of thousands of dollars in debt. PERIOD!!!
Sam: How has becoming a father changed your practice of pharmacy?
Donaye: It hasn’t changed. I still practice the same, but my desire to “move up” in the pharmacy ranks has decreased. For me, it’s more important to be present in my kids lives early. Often times, holding an important title beyond staff PharmD equates to less time at home.
Sam: Is there anything else that you would like to add?
Donaye: PAY OFF YOUR STUDENT DEBT EARLY!
Tim: I attended Phillips High School (now Phillips Academy) and graduated from Auburn in 1976.
Tim: I was influenced by the two pharmacists that worked at Cowgill Drug in North Birmingham, where my mother worked as a clerk. The owner, Franklin Little, was classy and professional, highly respected by everyone in the community. Everyone called him “Doctor Little”. The staff pharmacist, George Thompson, was a happy-go-lucky guy that seemed to enjoy his job immensely. I admired both very much and decided that I wanted to be a combination of the two.
Tim: In addition to the two already mentioned, I had the privilege of working a number of years for Jimmy Harrison, president of Harco Drugs, and Jerry Thomas, vice president of Harco. They made working for Harco seem like a family business, where everyone was important. When I decided to go back to work for Harco after Big B Drugs was bought out by CVS, I received a personal phone call from Mr. Harrison, telling me how excited he was that I was back. When he made the difficult decision to sell Harco to Rite Aid, he personally hand wrote a letter of apology to each of his pharmacy managers, explaining why he made the decision. It meant so much to all of us. He taught us the right way to treat employees and patients.
Tim: In addition to working at Cowgill as a teenager, I worked at Campus Drugs in Auburn (a Harco store) while in school. After graduation, I did my internship with K-Mart Pharmacy in Huntsville. After I received my license in 1977, I returned to Harco, working briefly in Talladega before opening a new store in Alexander City. I became homesick for my family and friends in Birmingham, and started working for Big B in 1979. I stayed with them for 17+ years until they were bought by Revco, then eventually CVS. By then, Harco had locations in Birmingham and I received an offer from them in 1997. I was glad to be back with the Harco family, but the Rite Aid deal was not long after. I stayed with Rite Aid for about another year. I began hearing rumors about Walgreens coming to Alabama, and started checking about possible employment. I had been told many years before “if you ever get a chance to work for Walgreens, take it!” I had the honor of being one of 3 pharmacists hired to open their first Alabama store, in Pelham. I now have 20+ years with Walgreens.
Tim: The PharmD degree has much more clinical component than the old Bachelors degree. In my opinion, at first, there was a shortage of practical experience with the PharmD students, but I believe that has been addressed and corrected now. When I graduated, the requirements were different in that we had to get the majority of our intern hours after graduation, which gave us about a year of practical experience under supervision. I probably learned as much in that year as I did in 3 years of pharmacy school. The PharmD students get great experience on their rotations in their final year. I think it would have been fun to do that while I was a student. For the most part, I’ve received nothing but respect from my students. They recognize that 40+years of experience counts for something, and that I know what I’m talking about (most of the time).
Tim: I think, over the years, the one rule that causes the most confusion, is the “two signature lines” rule. Technically, if a prescription blank does not have that, it’s not a valid prescription. I understand there is some talk about eliminating or modifying that rule.
Tim: I would tell a new grad that patient safety is the most important thing. If something is unclear, whether it is the drug prescribed, directions for use, potential interactions or contraindications, you must get it right. If you don’t get it right, it doesn’t matter how fast you got it to the patient. Ours is one of the few, if not the only profession, you have to bat 1000, or there’s a problem.
Tim: Student pharmacists are so well educated these days. I feel that sometimes I learn more from them than they do from me. As far as being harder or easier to teach, it depends on the student. Some come to me with no experience in retail. There is a learning curve for them. Five or six weeks is not long enough to learn everything we have to deal with. The ones with retail experience are usually the easiest. I would estimate that I have had close to 500 students, including students on rotation and students that worked part time. I often wish that I had kept a scrapbook of all my students over the years.
Tim: Yes, and no. Pharmacy, especially retail pharmacy has changed so much over the last 42 years. I never dreamed that I would be administering immunizations. I never imagined the impact that third party payors would have on the profession. I never thought I would have to deal with a drive thru window.
Tim: The profession has been good to me. It has given me a nice income, and a sense of being a part of something that helps people. I have derived much satisfaction from mentoring students that went on to be good pharmacists, and any time a patient thanks you for what you do for them, well, it doesn’t get any better than that.
The practice of pharmacy grows by leaps and bounds each and everyday.
The education of Student Pharmacists to take on both current & emerging roles in providing pharmaceutical care has occurred and continues to evolve. I have a firm belief that this education will satisfactorily meet and exceed the needs of both current and future patients.
While the Pharmacists education is well defined in that Boards of Pharmacy and National Associations have criteria that you must meet prior to entry into the profession. The Pharmacy Technician’s education is not as well defined. Currently technicians are educated by for-profit institutions, some but not all Community Colleges, and there are some online programs.
How can Pharmacists fully utilize their education and knowledge in both current and emerging markets – if there is not an appropriate and affordable education model to satisfactorily keep pace with pharmacy technician demand in the market?
It’s my opinion that the greatest demand for the Pharmacy Technician will be in the retail sector. There is a high turnover rate in this market and typically this is the space where an organization can take on registered pharmacy technicians that have no pharmacy experience. With an increase in mergers and acquisitions between chain pharmacy, benefit managers, and health insurers – the demand for registered pharmacy technicians will continue to increase.
Current state laws will also need to keep pace with changes in how both Pharmacists and Pharmacy Technicians are utilized in the Pharmacy.
- Pharmacy Technician verification via Barcode technology (http://www.ajhp.org/content/73/2/69?sso-checked=true)
- Medication therapy management
- Pharmacist Practitioners
- Collaborative practice models
- The increased market-share of “specialty pharmacy”
- Compounding pharmacies regulated by federal guidelines USP 795, 797, and 800
These are all topics to consider when considering the job market and demand for both the practicing Pharmacist and Pharmacy Technician.
What can fill the education gap?
I had never heard of the “Ready to Work” initiatives taking place in Birmingham, AL. But after meeting Ms. Dorothy Henry and leadership at Lawson State Community College — I stumbled upon an institution that is at the forefront of this community based initiative.
Ready to Work programs can offer job seekers foundational knowledge to take on entry level job positions. “Ready to Work” educational healthcare tracks include medical assistant, patient care assistant, and pharmacy technician. These programs help folks learn how to become registered and/or certified to take on entry level positions in the workforce.
Having a job that you care about and enjoy is good for the individual because it increases self-worth. It’s good for the family because it provides a stable source of income. It’s great for both the community and local economy because the money can be recycled into tangible purchases of goods, services, and long term assets.
I’ve had the pleasure of working with folks interested in becoming registered Pharmacy Technicians through this program. And I really believe that this could be an opportunity where more Pharmacists can serve and become involved in helping young people find a career in their local community. Programs like this help to ensure that there are affordable avenues for people to learn and become aware of professions that can be a source for both a rewarding career and steady income. I have posted my lecture materials online at www.samblakemore.com . Feel free to follow along and give back any comments and/or positive feedback.
The Dispense As Written Codes that I use regularly in my practice are:
DAW 0 = NO PRODUCT SELECTION INDICATED
DAW 1 = SUBSTITUTION NOT ALLOWED BY PRESCRIBER
DAW 9 = SUBSTITUTION ALLOWED PLAN REQUESTS BRAND
Why is this important?
Dispense as written codes are important in billing/filing claims correctly to a patient’s insurance plan. Claims must be billed/filed correctly so that patients receive the appropriate drug products at the correct price.
For me… DAW 0 is used most of the time (this holds true for most pharmacists), while DAW 1 is used sparingly; a drug example for those who are not Pharmacists as to when a Pharmacist uses DAW 1 is seen in the case of prescribing Brand Name Synthroid. Prescribers often write for Brand name Synthroid instead of Levothyroxine because this drug has a Narrow Therapeutic Index (NTI). Due to the NTI, formularies often include both the Brand and Generic products on their formularies so that patients receive appropriate pharmaceutical treatment for their thyroid conditions.
If you’re interested in reading more about NTI, please visit the FDA’s website and review the powerpoint “Quality and Bioequivalence Standards for Narrow Therapeutic Index Drugs.”
DAW 9 is increasingly becoming popular and being put into place by Pharmacy Benefit Managers (PBM’s). Typically generics have been dispensed because the generic product is the cheaper alternative when compared to the brand name product. However, increasingly manufacturers have been offering PBM’s rebates for the monies that they pay the pharmacies on the drugs cost.
In short…even when prescribers write a prescription and sign Product Substitution Permitted — the pharmacist must dispense the brand name product for the product to be covered by the patient’s insurance. This is done by changing the computer DAW code from a 0 to a 9.
So you may be asking, “how is it more profitable for the PBM’s to have higher priced drugs on their drug formularies?” I found a great article published by NCPA entitled “PBM Revenue Streams and Lack of Transparency”. The article is a quick read and outlines why Brand Name products continue to be on formulary even when a generic competitor enters the market.
Examples of using DAW 9 in my practice (Generic Drug — Condition Treated)
Dexmethylphenidate ER — ADHD
Diazepam Rectal Gel — Seizures
Methylphenidate ER — ADHD
Budesonide Respules — Asthma
What’s the effect on people and the market?
In my practice this leads to a major consultation point…
- You and/or your family member is on a drug that insurance is requiring that Brand Name be dispensed (DAW 9). I’m not sure if your local pharmacy carries the Brand Name or Generic product. Thus, it is imperative that you contact your pharmacy days in advance to ensure this product is in stock when you attempt to refill your medication. If you don’t call ahead of time, this could potentially delay when you receive your medication, which could lead you to become non-compliant with your medication(s).
The reason that this is so important…
- Finding the medication for your patient is important…but ensuring that your patient has access to this medication is just as important. If they can’t obtain or access the medication, then you can’t ensure their compliance on the medicine. And non-compliance ultimately can lead to hospital readmission.
- When patient’s transition from an inpatient admission to being discharged to the outpatient setting, prescribers are often unaware of what’s on or not on the patient’s drug formularies. This can lead to confusion and delay and/or impede discharge planning which can potentially lengthen their hospital admission.
DAW 0 versus DAW 9 seems like such a trivial issue, but the increased prevalence of this small change can impact our patient’s compliance and can drive up the cost for providing healthcare.
If you have Questions related to this topic? Please feel free to leave a comment.
My Operations Management (OM) Professor in B-school had one question for our final exam.
Explain if this course will or will not be relevant in your chosen profession or career path?
I revisited my short summary a few days ago and considered the role of the Pharmacist in relation to the current healthcare model. How can Pharmacists help create efficiency when we see inefficiency? How can individual Pharmacists help bring order to a process and fill in the gaps when we see an opportunity to help?
I believe the Pharmacist can fill in the “gaps” and find an opportunity to serve in new ways. This will further our value to the healthcare team. Dispensing medications correctly should always be the foundation of our Profession, yet there are more bricks to be put in place to create the final framework in our bid to be seen as “healthcare providers”. With the broad knowledge base that Pharmacists have in their toolbox, there is an opportunity to be more than “retail or clinical.”
December 4th 2015 at 9:53PM I submitted the following.
Sam Blakemore, PharmD
Personal Operations Management
I have been a practicing Pharmacist for three years. In that time period, Walgreens purchased Alliance Boots, CVS Caremark purchased Target’s in store pharmacies, and most recently Walgreens made another large investment in agreeing to purchase Rite Aid Pharmacies.
The number of patients that the healthcare system takes care of will continue to rise due to more people having access to healthcare with the implementation of the Affordable Care Act. Yet, the reimbursements for these services has become more competitive due to increased demand for better pricing by federal and state funded programs.
The Affordable Care Act has made mergers the new norm. Hospitals, Pharmacies, and Home Health Care Agencies have decided that the key to survival is to become as “lean” as possible. In becoming “lean”, the merged companies streamline operations by initiating new workflow processes, retire outdated facilities, and layoff under-performing workers in the hopes of increasing productivity and profits.
Mergers within the pharmaceutical industry are creating shifts in the supply chain. This will impact the drug companies, wholesalers, and retail pharmacies both independent and chain. In the article Drug Partnership Could Trigger Major Supply-Chain Changes, the author states the following:
For now, drug manufacturers mostly use wholesalers like AmerisourceBergen to ship their product to pharmacies. But if manufacturers are squeezed too much by the arrangement, some could opt to bypass wholesalers altogether and peddle their drugs straight to the drug stores…1
Pharmacy mergers have increased for the purpose of survival in a market with a reimbursement structure that changes by the day. In the article, Reassessing the pharmacy supply chain for a healthier bottom line, the author states the following:
The unpredictable and shrinking reimbursement landscape requires these organizations to reassess expenses and processes –especially within the supply chain—across all facilities and departments to determine cost-effective operational strategies.2
Forecasting reimbursement and cost of drugs in pharmacy is key to success. As an example, Rite Aid Pharmacies earnings per share decreased due to a cut in Medicare reimbursement rates.
Rising generic drug prices are hurting drug store operators as insurers and pharmacy benefit managers have been slow in raising reimbursement rates for those drugs…reimbursement rates for Medicare Part D drug plans, which cover prescription drugs for senior citizens and the disabled, are falling due to growing competition to win these contracts.3
Appropriately forecasting revenues and expenses, using lean/six sigma principles to eliminate drug errors, and having a firm grasp of inventory management are the big three principles I will remember from this course. Having a firm grip on these concepts can be the difference between thriving and failure in this market. It is imperative that a pharmacist have a firm grasp of operations management to thrive in this market and differentiate one’s self against other pharmacists they’re competing against for a job.
I want my patients to have a good experience. I want them to receive the right drug, at the right dose, at the right time, and for the right price. With that in mind, this quote grabbed my attention when I first read it.
“With the country focused on controlling the escalating costs of healthcare, every entity in the healthcare system is under increased pressure to lower costs—while at the same time not jeopardizing the quality of care that patients receive.”4
It is my opinion that schools of medicine, nursing, pharmacy, public health and so forth should require or offer as an elective an operations management course. This course has challenged me to reconsider how I manage employees and myself. This operations management course offered me the information, vocabulary, and resources that I’ll be able to draw from in a healthcare environment that is rapidly undergoing change due both to increased competition and decreased net margins.
1.) Martin, Timothy W. Drug Partnership Could Trigger Major Supply-Chain Changes. 22 March 2013. http://www.wsj.com/articles/SB10001424127887324373204578374801163395308. Accessed 23 Nov. 2015.
2.) Piotrowski, Cary. Reassessing the pharmacy supply chain for a healthier bottom line. 17 July 2015. http://www.beckershospitalreview.com/finance/reassessing-the-pharmacy-supply-chain-for-a-healthier-bottom-line.html, Accessed 18 Nov.
3.) Ramakrishnan, Sruthi. Rite Aid cuts full year forecasts citing reimbursements. 17 Sept. 2015. http://www.reuters.com/article/2015/09/17/us-rite-aid-results-idUSKCN0RH1I920150917#BMoHOwRPdPZFJMVo.97. Accessed 18 Nov. 2015.
4.) Pharmacy Inventory Project: Improving Inventory Management at Genesis Healthcare System Pharmacies. 19 Nov. 2014. http://fisher.osu.edu/supplements/10/14252/white_paper_genesis_2014_2.pdf. Assessed 18 Nov. 2015.
It’s not always about how much money a business makes; oftentimes its more important to understand how much money the business can save.
I asked a Pharmacist the following question:
“Who is probably the most famous and richest industrial engineer? Your hint… he grew up in Mobile, AL?”
He paused and thought about it for a few moments…
Then he said, “I’m not sure…who?”
I said, “look at your smartphone… Tim Cook ring a bell…”
Tim Cook…iPhone…ring a bell…”HAHA.” I know…I know…so funny, not really. Our discussion began when he asked me about my experiences in B-school (business graduate school). I discussed various points in my journey as a manager, and how I sought some answers to my many managerial questions. B-school helped fill some of those gaps.
Quantitative Analysis for Managers I explained was an interesting but difficult course. I really had to work hard to put all the concepts together. It was business math on steroids. A taste of algebra with a pinch of calculus and a dollop of excel spreadsheet. One week we were discussing linear programming models; the next week we were discussing transportation models.
I felt like I could study all week for the tests, and still not feel good about my prospects of passing. The Professor would allow us to have a formula cheat sheet, but that was of little value. The course took time and was intense. The tests were tough. He ended up curving our final grades that semester.
It was tedious work. It took time to wrap your mind around some of the concepts; but studying those concepts gave me satisfaction. My mind was being pushed and thats what I wanted as a student. It made me appreciate the skill and art it takes to make complex business processes less complex. I began trying to understand the formulas behind business principles. I enjoy learning about a Professor’s educational background. It always explains why some concepts just feel so natural to the teacher/lecturer. Turns out our Professor that semester was an expert in the field of industrial engineering. I had heard about civil engineering, chemical engineering, electrical engineering, etc.. But I had never heard of industrial engineering.
Pharmacist in general have an appreciation for math and science. So I decided to show my Pharmacist “buddy” an old video on linear programming that the Professor had uploaded on the web. The Pharmacist became “giddy” with anticipation on how to setup the correct mathematical equation to reach an appropriate business decision based on profitability.
We then lightly touched on transportation models…
I said, “driving a 18-wheeler seems simple enough…but then imagine all the routes and paths those trucks can take to get to their destination.”
He said, “yea…that’s right…isn’t that why some mail couriers only take right hand turns? That’s why they have people doing that research…think of all the money they save on gas, and all the time they save by making routes more efficient…”
I said, “you know where most of these principles fall under? Industrial engineering…”
Industrial engineers bring science to our everyday lives by engineering efficiency; they use math to bring order to a process. Pharmacists practice the same methods with medications. We ensure patient safety by being the medication experts of the healthcare team. We bring order and create efficiency in the dispensing and consumption of medications.
So what’s stopping Pharmacists from reaching our full potential as the “industrial engineers” of drug management? Gaining status as “healthcare providers” will go a long way in creating a structure for the reimbursement of our services. But until that “provider status” reaches all 50 states; what can our Profession do to show the “system” our value?
Currently the market is focused on volume to magnify shrinking profit margins. However, the market will gradually shift to a focus on reducing costs. In part because rising costs will lead to skyrocketing debt in our current healthcare model. The market is at risk of collapse due in part to rising medication costs. While we can’t control how Pharma prices new drug regimens.. Pharmacists can be on the front lines of change by initiating the following principles:
- Limit “defects”–use “lean” principles to ensure patient safety and accurate dispensing of medications with appropriate operations management principles
- Improve discharge planning—ensure patients receive the appropriate medications upon discharge.
- Improve access—ensure that upon discharge from hospitals or clinics; patients have access in the community to the appropriate medications from local pharmacies, mail-orders, and patient assistance programs.
- Engage in dialogue with prescribers—regarding the prior authorization process, formulary additions and deletions, an analysis on patterns seen at the pharmacy in the local community.
- Build an alliance—with social workers, churches, community organizers so that when patients need help the Pharmacist can give guidance.
- Data mine–effectively gather data about medication usage and prescriber patters; then turn data into usable information to enhance quality of care.
- Reduce expense—have an active engagement in knowing the costs of medications, and the copay tiers of pharmacy benefit managers. Have an active discussion with patient’s and their families regarding their ability to manage these expenses.
There are more PharmD’s graduating with dual degrees; Pubic Health, Business, and Law. There are more PharmD’s entering pharmacy school having already obtained a bachelors degree. The “Millenial PharmD” has the potential to step outside the box to meet the changing demands of the market.
My version of the Pharmacist Industry Engineer (PIE) does not epitomize the traditional meaning of Pharmaceutical Industrial Engineering in that traditionally the framework of the definition was focused on manufacturing for “Big Pharma”. I simply seek to use this term to reframe how we are defined as agents of change in the current marketplace.
A PIE as defined by me—both optimizes and individualizes pharmaceutical care, creates new processes to improve pharmacy access, improves operations to ensure patient safety, and builds communication channels with both prescribers and patients to reduce waste and expense for the individual and healthcare system.
Efficiency. Accuracy. Reduced Defects. Reduced Costs.