NEW YORK CITY PHARMACISTS SOCIETY How To Survive A · NEW YORK CITY PHARMACISTS SOCIETY President’s Message VOLUME 26, ISSUE 7 PSSNY hELPLINE 1-800-632-8822 OCTOBER 2017 The Voice

N E W Y O R K C I T Y P H A R M A C I S T S S O C I E T Y

President’s Message

VOLUME 26, ISSUE 7 PSSNY hELPLINE 1-800-632-8822 OCTOBER 2017The Voice of Pharmacy in the Big Apple www.NYCPS.org

Happy Diwali & Jeff Bezos to one and all! Happy Diwali and Happy New Year. Di-wali is celebrated by Hindus, Jains, and Sikhs and Newar

Buddhists to mark different histori-cal events and stories, but they all symbolize the victory of light over darkness, knowledge over igno-rance, good over evil, hope over despair. This Knowledge over ignorance gives importance to revisit Amazon. Recently I have read an Open Let-ter of Amitai Etzioni a Professor at The George Washington University which was intended for Jeff Bezos. Jeff Bezos is the founder and CEO of Amazon. I encourage everyone

to take a few minutes and read the open letter. The link to the letter is https://qz.com/1090762 The author, Amitai Etzioni, goes on and on about the current flawed health care system. She explains the massive amount of inefficien-cies, waste, and fraud in our current healthcare model. There is a lot of disruption necessary. We need to learn how to protect our pharma-cies, our patients and also our Pro-fession. Every Profession and Trade faces difficult and uncertain times. No other threat is quite as large as the giant monster, Amazon. Early this month CNBC has reported that Amazon is on the brink of deciding if it will make a big move into sell-ing Drugs online. We once worried

continued on page 7

OFFICERSParthiv Shah, President 718-292-4244Aniedi Etuk, President Elect 212-222-3652Bill Scheer, Treasurer 917-805-4207Jim Schiffer, Secretary 212-616-7069

BOARD OF DIRECTORSRon DelGaudio, Chairman 718-230-3535Stephanie Alvarez 347-860-1390 Ilana Aminov 212-929-7527Charles Catalano 718-358-1300Mike Agovino 718-543-3116Charlie Ciaccio 718-452-3261Vito Columbo 718-418-9700Jim DeTura 718-292-1856Aneidi Etuk 212-222-3652Russell Gellis 212-877-3480Carol Georgiadis 718-762-7111Roy Greif 718-363-3300Robert hopkins 516-852-1405Ray Macioci 718-823-1085Boris Mantell 347-276-5566John Navarra 212-213-5570Joseph Navarra 212-213-5570Boris Natenzon 718-720-3710Roger J. Pagenelli 718-364-6100Dhiren Patel 212-281-0488Alex Perchuk 718-835-2000Richard Schirripa 646-590-1154Mohammed Taher 718-827-7528

PSSNY REGIONAL REPSParthiv Shah BronxDhiren Patel ManhattanBoris Natenzon Brooklyn, Staten IslandRobert hopkins Queens

RECORDING SECRETARYIlana Aminov 212-929-7527

NEWSLETTERJim Schiffer, Senior Editor 212-616-7069Designed, Printed & Mailed by: GBV Printing Services 631-231-7300

IN THIS ISSUEPresident’s Message ......................1DEA Inspection Series .......................1PSSNY President’s Message ...........3Treasurer’s Corner .........................4A Message & Greetings from PSSNY Executive Director ..............4A Message from PSSNY Chairman Russell Gellis ..................7Secretary’s Report ..........................8Amazon May Be Putting Their Toe In The Pharmacy Waters .......................8PSSNY Albany Legislative Report ...11Update on Opioid Epidemic New York and New Jersey State Action .................................11News from Around the Pharmacy World ...........................12NCPA ..........................................17PAAS...........................................17RX and the Law ...........................18Retail Council...............................22ISMP ...........................................25

If there Is a “d” or “Vd” on your label... you’re delIquent or Very delIquent. please remIt.

for further InformatIon call 1-800-632-8822

The New York City Pharmacists Society111 Broadway, Suite 2002, New York, NY 10006

ADDRESS SERVICE REQUESTED

Recently, Jim Schiffer was men-tioning to me that the civil fines im-posed by the DEA have increased substantially. Apparently, he has been dealing with federal prosecutors from the Manhattan United States Attorney Office and he was advised that civ-il fines had double and more in some cases. The Drug Enforcement Admin-istration (“DEA”) through their Office of Diversion Control (“Diversion”) has tar-geted prescribers and pharmacies as the number one reason by there have been an increase in deaths from Hero-in and other opioids. If you didn’t watch last weeks “60 Minutes” segment on this subject, you should see it. DEA Diversion maintains a sys-tem that they can see every order that a pharmacy place for opioids such as Oxycodone, Hydromorphone, or Mor-phine Sulfate. If your pharmacy is the target of a DEA inspection, you need to

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How To Survive A DeA Inspection Series:

DeA and the New Civil Fines

PAGE 2 OCTOBER 2017 NYCPS NEWSLETTER

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NYCPS NEWSLETTER OCTOBER 2017 PAGE 3

Food for Thought... I read a thought provoking article a few days ago, “An open letter to Jeff Bezos-you are needed to disrupt the healthcare sector” by Amital Etzioni. He wants Mr. Bezos to “challenge the health care plans old ways of doing business. The whole healthcare system needs his kind of shake up, to cut costs to consumers while still making a profit.” This would not be an easy task, to say the least. When it comes to pharmacy, he states that it’s a hardship for patients and/or their families, to pick up their medications. Amazon certainly does know how to do “delivery” but would it work for medications? (I have my doubts that it would be as easy as this author thinks.) The author discounts the value of the personal touch and counseling by saying that very little counseling takes place, so patients wouldn’t mind using “Amazon pharmacy.” He says Amazon can provide the patient with a more reliable stream of medication information, rather than relying on a pharmacies’ software. He cites the Chicago Tribune investigation, done in 2016, that had dismal results. Pharmacists did not warn of a fatal drug-drug interaction between two drugs, 52% of the time. (Improvements have to be made in the computer systems ability to identify important drug-drug interactions, and communicating information to our patients. So many software systems identify things that are insignificant, leading to pharmacist having “alert fatigue,” making it difficult as the day wears on. The author discusses the ability of Amazon to negotiate prices, decreasing unnecessary medical

procedures, and possibly decreasing costs in Medicare by Billions of dollars, and improving outcomes, decreasing fraud and waste more efficiently than the Federal government can. (Sounds so simple when this educator/author says it!) I am sure that “Big Pharma” would not welcome Mr. Bezos and the “pressure” he could bring if he were to accept the challenge. As Pharmacists, we have the advantage of being part of A HEALTH CARE TEAM, to improve patient’s quality of life, with our best service. Be innovative in your service to your patients, to keep up with change. Things are moving FAST and FURIOUS these days! Remember PSSNY is conducting an awesome Mid Winter Conference in Albany New York, during Friday, Saturday and Sunday January 26 through 28, 2018 at the Desmond Hotel. It is never dull nor boring at these events. Please join us, plenty of updated pharmacy health care information, Continuing Education events and networking opportunities with your friends and colleagues.

Stay well and stay connected with your collegues,~ Roxanne Richardson, R. Ph.

PSSNY President

PSSNY PreSideNt’S MeSSageRoxanne Richardson was installed as the 128th president of the Pharmacist Society

of the State of New York on June 24th, 2017. Roxanne is currently a pharmacist working in a local hospital in the Auburn New York region.


We have an opportunity before us to help educate our state and national legislators about the culprit behind the rising costs and decreasing margins in the prescription drug marketplace. The PBM industry is that culprit. Even our Governor recognized the heart of the problem, when he included in his budget proposal the regulation and licensing of these huge companies who hold manufacturers, insured entities and pharmacists’ hostage to their avarice. Our state society, PSSNY, in conjunction with the NYS Chain Pharmacy Association were on the same page trying to get this idea of PBM regulation through the legislature this past session. Unfortunately we were not able to have a bill pass both houses. We need to mount a campaign in this the off year for elections for the legislature to secure passage in the upcoming legislative session. As pharmacists we are crucial to garnering support from the voice the legislators pay attention to, the patients we see every day. There is a clamor in the local newspapers, news programs about the increased costs of certain essential life saving drugs. Insulin is one such drug that hits home with many of our patients. Cost along with co pays have risen as a result of manufacturers having to pay to play, that is offer financial remunerations to be included on certain formularies. We need to visit with our Assemblyperson and state Senator in this quiet time before Albany kicks into high

gear in January. PSSNY has resources available to help you get this issue across to these legislators. But as we all know these tools can’t get in front of our legislators by themselves, you are the part of this equation that will help us get action. We cannot be complacent, especially today, when so much is at risk. It always comes down to it being our responsibility because there will be no one who can express our issues better. This also applies to the national arena where NCPA has introduced a bill “Improving Transparency and Accuracy in Medicare Part D Drug Spending Act” (S. 413 / H.R. 1038) into this congressional session which will prohibit Medicare Part D plan sponsors/PBMs from retroactively reducing payment on clean claims submitted by pharmacies under Medicare Part D. To back up this bill NCPA has commissioned an actuarial firm to “score”this bill (give a savings value to the budget from this bill) the actuaries came up with 3.4 billion dollar savings over ten years from this legislation. Again the success of this bill and a positive effect for community pharmacy rests with us. We need to speak to our Congressperson and our NY Senators, asking them to cosponsor this two house bill. NCPA has resources for you to use to speak to them, but again the resources are just resources and pharmacists need to present the facts, if we want success in relieving the onus of the PBM deceptive practices we all see in our bottom line. Honestly how hard is it for pharmacists to step up and enlighten those who can protect our businesses? We cannot afford to wait or to think that someone else will take the step to fix these problems. We are the only ones who can and should take our case up. It is up to us now!

- Bill Scheer, R.Ph. © 2017, Bill Scheer

treaSurer’S CorNerITS OUR TIME NOW

Grassroots Advocacy: The District Office Visit As outlined in Russell Gellis’ message, PSSNY has developed a Grassroots Advocacy Toolkit www.pssny.org/grassroots to develop a network of local advocates that can be activated on various issues as needed. One key strategy in meeting that goal is the district office visit with your legislator. For Albany lobby days, PSSNY staff handles the logistics, but for a local visit that will be up to you.

Meeting with your Elected Representative How do I request a meeting at the local district office? It’s as simple as calling the office. Legislators’ offices

are listed on the Senate and Assembly websites (http://www.assembly.ny.gov/mem https://www.nysenate.gov/senators-committees). Ask to speak to the legislator’s staff person who is responsible for scheduling. State that you would like to meet directly with the legislator. Ask about the meeting request procedure. Some offices prefer to take meeting requests by phone. Others will ask you to submit the request by email. In any event, you will be asked for the topic of the meeting since legislators deal with wide ranging issues. Follow the process, being sure to take note of the scheduler’s name to smooth the way for follow-up calls or other meeting requests. Allow a few weeks for the office to schedule the meeting. Before you meet, read the profile on the Senate or Assembly website. How long has the legislator held office? What is the district (e.g. towns, neighborhoods, etc.)? Does the legislator represent the district where you live or where you practice? Notice the committees on which the legislator serves to understand the topics

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grAssroots ADvocAcY: inFluence At the locAl level

As a pharmacist you are a constituent, an expert in pharmacy matters, and an important participant in the healthcare delivery system in New York State. When you take an active role as an advocate for pharmacy, you are doing your part to make sure that issues facing the profession, your patients, and your economic future are addressed in Albany. The Governor and the New York State Legislature, both the state Senate and Assembly, have an enormous impact on every aspect of pharmacy practice including its future in an evolving healthcare system. Elected representatives are very responsive to their constituents. Because they need votes to stay in office it is their natural inclination is to get to know their voters, address local problems and understand what they can do to help.

Grassroots Advocacy PSSNY’s goal is to build an effective and dynamic grassroots network. Grassroots advocacy refers to ef-forts by individuals and organizations at the local level to influence the public policy debate at the State Capitol. Grassroots advocacy involves constituents communi-cating with legislators and the public through the press, by writing letters, sending emails or faxes, or circulating petitions that will be delivered to a selected legislator or legislators. These forms of advocacy focus attention on an issue that would otherwise not be visible or well understood. They serve to convey the importance of issues to legislators and your patients, creating an impe-tus for action.

PSSNY has developed a grassroots advocacy toolkit that we will use to engage pharmacists in this process. Issues and talking points will change over time, but the network we build will strengthen pharmacy’s relationship with elected officials. Some of the tools outlined in the kit include:• District Office Visits• Letters to the Editor• Petitions• Pharmacy Visits• Ultimate Goal Your goal as a grassroots advocate is to develop a friendly, respectful working relationship with the New York State senator and assembly member who represent you in Albany. As a constituent and voter you are important to elected officials, and as a pharmacist you have an authoritative voice on issues with direct bearing on the profession. Effective constituent relationships can translate into success at the legislature. PSSNY will be attending affiliate board meetings and membership meetings to explain and discuss how to turn this toolkit into action. You can see the toolkit at www.pssny.org/grassroots

PBM Issues To launch this grassroots advocacy effort we will create templates that will raise awareness for the need to register and license pharmacy benefit managers. The Governor’s proposal to do so last year did not survive budget negations so PSSNY wants to create buzz at the local level to convey that our patients need relief from the practices of these unregulated middlemen. We need to make it clear to individual legislators that PSSNY and our patients want to see action taken in the 2018 legislative session on this issue. Please stay tunes for more information and instruction. We need to let our elected representatives know we are not going away. We need action to be taken now to ensure patient access to community pharmacy. Additionally, please see Kathy Febraio’s and Elizabeth Lasky’s messages for more information.

Russell Gellis, RPhPSSNY Chairman

A MessAge FroM PssnY chAirMAn russell gellis

about the chain stores, we worried about Mail Order Pharmacies. We have survived them all. We are con-stantly annoyed about the closed net-works, reimbursement below cost, and DIR Fees; however we still man-age to get by. Our Industry is surviv-ing. New Independent Pharmacies are opening up everyday.

Let us all embrace our new role as pharmacist. More and more often in our daily lives, we need to step away from being product focused to more clinical service focused. Value based system will be mainstream sooner than later. All members should stay engaged with our local organiza-tion, NYCPS, and PSSNY & NCPA. Please help increase our member-ship for these important organiza-tions. Please help raise Political Ac-tion or PAC money. Please attend

our CE programs, conferences, and conventions. Collectively we will have the means to navigate the changing landscape. We must remember we have the knowledge, and ability as well as the fact that we represent the good in the Healthcare system. We will over-come our obstacles includ-ing Amazon.

Thanks for listening.~ Parthiv Shah

NYCPS President

President’s MessageFrom page 1


The summer is over and football season is upon us. We have plenty of issues to manage in this strange health care environment. There are many issues we face in our daily activity as a pharmacist. Here are just a few. I recently have had many pharmacists approach me for help regarding compliance with a taken for granted aspect of our profession. We have all expected to continue providing our services to our fee for service Medicaid patients. Be aware that the Compliance Unit at OMIG is conducting random audits of various providers including pharmacies to confirm that the provider is adhering to the very complex requirements of the NYS Social Services law which has been in effect for about ten years which requires an annual certification of the providers compliance with state and federal fraud waste and abuse laws and regulations. I have seen a number of pharmacies spend scores of hours with responses to the OMIG requirements on the pharmacies compliance program, and compliance officer’s responsibilities. If you are selected for such an audit I assure you it will be a painful experience. I suggest that you use a competent compliance consultant which will assist you with the responses to the compliance audit survey. As we gather for our monthly CE meetings you should consult with the leadership of NYCPS for more details. I could go on for hours on this topic. I suggest you review the basic issues as they are posted on the NY OMIG website; www.omig.ny.gov/compliance. Better to be prepared than to be caught with your compliance pants down to your ankles!!! Moving onto other NY Medicaid news, as you may have heard New York State has modified the method of payment for fee for service Medicaid reimbursement. The New York State budget which was enacted on April 1, 2017 called for a shift in calculating the reimbursement to pharmacies to reflect a move to the NADAC pricing model. NADAC stands for the National Average Drug Acquisition Cost as a benchmark for NY Medicaid reimbursement. In the words of the Centers for Medicaid and Medicare Services, NADAC has been prepared to create a national benchmark that is reflective of the prices paid by retail community pharmacies to acquire prescription and over-the-counter covered outpatient drugs. The use of NADAC is sweeping state Medicaid agencies from coast to coast. We

have not seen the actual NADAC pricing model yet because it appears that NYS has not yet been granted official approval to activate this pricing model. According to a memo circulating in New York State, the plan is to enact this pricing model shortly as NYS is awaiting federal approval. The upside of this NADAC pricing model is that we will now receive a $10.00 dispensing fee across the board, for brand name drugs, for generic drugs and for our over the counter dispensings. What we may see as a downside is some of the reimbursement rates being calculated for expensive brand name drugs and this NADAC model also encompasses generic drugs, with MAC prices and those without such prices, as well as over the counter drugs. We are uncertain as to how the price increases will be accounted for as well, as we have noticed strange patterns of price increases and we are not certain how NADAC will account for such changes in market conditions. The use of NADAC was done for several reasons, one being that Average Wholesale Price guidance is totally unreliable and unrelated to actual costs. New York Medicaid is circulating a news bulleting showing that the new pricing model will be put into effect as of November 2nd, 2017, going forward and once the federal approval is in place to go back to April 1, 2017, those in the Medicaid enrollment department will check out the obligations owed for each participating pharmacy. Just think about this retroactive adjustment process. An increase of dispensing fee for each brand name and generic drug, a surprise $10 dispensing fee on all OTC dispensings (keep your fingers crossed that this does not disappear) and then a recalculation of the drug ingredient cost based on NADAC pricing methodology. For generic drugs, the NADAC price compares the lower of federal Upper Limit pricing, State Maximum Allowable Cost pricing against a federal benchmark price and the lower of these three prices is the official NADAC price. For brand name drugs has an established methodology and the over the counter products are also established as a NADAC pricing scheme. All I can say is that you know your leaders of NYCPS and PSSNY will be looking out for your interests and rights through this mess. Turning to a different topic, how many of you are immunizers? This is a professional tool to enhance both your professional image and your bottom line. A call to the PSSNY office can help guide you through the immunization process. To those immunizers out there, isn’t it frustrating that you can handle Medicare patients but not commercial patients? Yet the chains can put signs outside their mega retail outlets to brag that they can accept ALL insurance for flu shots and there is no copay for most of the plans. Why not allow the independent pharmacies the same opportunities?

- Jim Schiffer, Secretary NYCPS

Se C r e t a r Y’SrePort OCTOBER

2017

AMAZon MAY Be Putting their toe in the PhArMAcY WAters…. News Flash as we go to press……It has been reported in late October that over the past year, and, without much attention, Amazon.com Inc. has gained approval to become a wholesale distributor from a number of state pharmaceutical boards, according to a review of public records. Industry analysts in recent weeks have raised the possibility that Amazon was eyeing this lucrative new business, posing a potential threat to such companies as Express Scripts as well as CVS Health, RiteAid, Walgreens. Drug store stocks all dropped on this news which many folks were anticipating since Whole Foods was gobbled up by Amazon this past summer. The list of such states includes New Jersey and it appears that a 13th state, Maine, is also pending. Amazon is well on its way to become the premier and most efficient operator in retail marketplace. We will continue to monitor the doings of Amazon in future issues of NYCPS Newsletter.


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View from the State Capital, Albany New YorkWe Want YOU!

Educating our NYS Legislators about PBMs: A Fall Campaign

Governor Andrew Cuomo understands that the pharmacy benefit managers are responsible for driving up prescription drug costs. That’s why he described his Executive Budget proposal to license and regulate PBMs as a strategy to control costs. As you know, this proposal was not included in the final state budget. PSSNY and the Chain Pharmacy Association lobbied in favor, and it was supported by the Assembly and a number of individual senators, but ultimately it was defeated by the PBM industry and aligned business interests including the Business Council and health insurers. It is too early to know whether the Governor will include the same proposal in his Executive Budget for 2018-2019, but one thing is certain: PSSNY strongly supports state oversight of PBMs. In fact, PSSNY is focusing a grassroots lobbying campaign this fall on PBM licensing in the State of New York. The fall of 2017 is a sweet spot in the legislative calendar because these are the months between the first and second years of the two-year session, legislators have introduced their bills and they are not campaigning as they were in the fall of 2016 and as they will be in the fall of 2018. Pharmacists are perfectly situated to educate legislators and members of the public about issues related to PBMs. It goes without saying that pharmacists are accessible. Pharmacists interact with the public every day and see first-hand how PBM policies impact consumers in terms of formularies, co-pays and mandatory mail order. In fact, opportunities might be present themselves to mobilize consumers as advocates for state regulation of PBMs without violating the terms of pharmacy contracts.

What pharmacists may not realize is how unique and politically powerful this local presence can be. Pharmacists and patients are natural allies. Both are constituents as well as voters and have the potential to form an effective alliance on the issue of regulating PBMs. The two page document entitled “New York Should License Pharmacy Benefit Managers” presents a list of facts from independent sources that have appeared recently in articles published in widely circulated business journals and magazines. This piece is part of the toolkit deliberately designed to be factual and authoritative. Please use this piece as a discussion document or a leave-behind when discussing the need to license and regulate PBMs with a state senator, assembly member or a member of the public. To demonstrate the power of these articles, here are a few sample quotes: “Where PBMs are starting to get into trouble is that they are making bundles by keeping each player they deal with – pharmacies, insurers, drugmakers – partly in the dark. And those bundles, you could argue, are coming at the expense of people who pay for health care.” (L. Lopez. “These companies you never heard of are about to incite another massive drug price outrage.” Business Insider. September 12, 2016.) “Criticism of PBMs has accelerated as the industry has consolidated and grown more powerful, while also more aggressively steering patients to drugs with the largest rebates.” J. Walker. “Drugmakers point finger at middlemen for rising drug prices.” Wall Street Journal. October 3, 2016. “For many cheap generic medicines, copays sometimes are more expensive than if patients had not used insurance at all.” J. Hopkins. “Sworn to secrecy, community pharmacies forced to stay silent as customers overpay.” Bloomberg News. February 24, 2017. “Now an executive says the company can’t cut the product’s price because middlemen who manage drug benefits would refuse to cover it.” C. Chen and R. Langreth. “Gilead executive says pharmacy benefit managers keep price high.” Bloomberg News. March 3, 2017 Toolkits are useful only when they are used, and opportunities to talk about the role of PBMs present themselves every day. This is a call to action. Regulating the middleman in New York is a daunting uphill battle, but it can be won.

Elizabeth LaskyCapital Public Affairs, Inc.

PSSNY Albany Legislative Report

This is an update on several key issues, which affect the practice of pharmacy here in New York State. You should already be familiar with the terms relating to these proposed pieces of legislation.

Both New York State and New Jersey have recently changed their regulations as to the dispensing of Opioids to our patients. New York limits the first dispens-ing to a patient to a 7-day supply while New Jersey has made the regulation a bit stricter with a 5-day limit. How do you interpret these regulations is an important for you to remain compliant with your state regulations?

You may not know this but Tra-madol is an opioid and as such is in-cluded in this NY 7-day rule and the New Jersey 5-day rule. As we go to press, we are wait-ing for answers to a follow up ques-tion. We are uncertain as to what a New York Pharmacist should do on a New Jersey based opioid prescription. I would think the prudent thing to do is to limit the dispensing to a 5-day (NJ Regulation) supply by confirming such

with the prescriber. Regarding the a 7-day (New York Regulation) for a first fill I know that New Jersey pharma-cists are confused as to what to do. Calls have been place with the both boards of pharmacy for clarification. Additionally prescribers in New Jersey must enter into a pain management agreement with their maintenance pain patients after the third dispens-ing. More details will follow in future editions of the NYCPS newsletter.

uPDAte on oPioiD ePiDeMic neW York AnD neW JerseY stAte Action


Jim Schiffer reporting...News from Around

The Pharmacy World

OCTOBeR 2017 eDITIONNational Health Care Update / Medicare Part D Much has happened since our last issue. Health & Human Services Secretary Thomas Price is now eligible for unemployment since he has been let go by President Trump due to Price’s personal travel gate scandal. It seems that cabinet officers thought that they could take advantage of extravagant travel on government planes when an automobile or train would serve the needs at a much more reasonable cost to taxpayers. The effect on our healthcare issues with the loss of Secretary Price is yet to be determined. In the meantime, our sole pharmacist in congress, Congressman Buddy Carter has started a petition drive to bring attention to HHS on the abuses brought by the Prescription Drug Plans (PDPs) and Pharmacy Benefit Managers (PBMs) with the outrageous DIR fees charged on Medicare Part D patients. This petition drive was intended to be sent through Congressman Buddy Carter and then submitted to HHS Secretary Tom Price. Now that HHS Secretary Price is gone we need to learn who will carry the torch for pharmacy in this important issue. In a recent pharmacy meeting which was attended by Congressman Price, he was quoted as stating the annual cost of Direct and Indirect Remuneration (“DIR” Fees”) to the Medicare Part D plan is approximately 3.8 billion dollars. That money is being sucked out of the pockets of the pharmacies that are participating in the Medicare Part D prescription program without benefiting the Medicare Part D patients nor the federal government who is subsidizing the Part D program. There are loopholes in the Part D program guidelines and the industry analysts are always looking for ways to beat the system. For instance, Humana charges, back pharmacies that fail to complete a desk audit when so requested a huge penalty of 25% calling it an administration fee for the failure to complete the audit in the time demanded. By calling it an administration fee Humana POCKETS that money completely! One local NYC pharmacy that I know is challenging the charge back because the pharmacy owner claims never to have received the desk audit notice (Humana claims a particular person signed for the audit via UPS delivery yet the pharmacy owner has nobody

employed by that name). This administrative fee should not go in the pocket of Humana while Humana is administering a Medicare Part D Prescription Drug Program in New York State and ethically should put all such recoveries in a kitty to be credited to the Part D patients enrolled in their NY PDP. If indeed Humana could not keep that fee they probably would not be charging it in the first place. Just another one of millions of unfair tactics brought upon the pharmacy profession by the prescription insurers and their Pharmacy Benefit Manager cousins. Boy do we need legislation to reign in these monsters! The annual re-enrollment/open enrollment of Medicare Part D patients is once again upon us. 2018 commences the 13th year of this senior prescription benefit. It remains a very confusing and complex program but it seems to work. Interestingly the monthly cost to patients remains relatively competitive. Some of the New York plans are running for less than $15 per month per member. However, access to community pharmacies continues to become more difficult. While the law that created Medicare Part D requires access to all pharmacies, there was included a section of the regulation that permits preferred and non-preferred pharmacy participation. That provision has created heartache for the independent pharmacies. Chains are making deals with the various Prescription Drug Plans (PDPs) to give lower or zero copays on generic drugs for that preferred status. A patient on six or seven drugs may save over $50 per month in the copay spread (preferred versus non-preferred pharmacy) by selecting a preferred pharmacy. Seniors on fixed income many times don’t have a choice. This aspect of the Medicare Part D program needs to be fixed, but will it?

The Opioid Crisis On October 15, 2017, the Washington Post and CBS 60 minutes released a TV/print media story as well as a detailed Washington Post story on the conflicts in the Drug Enforcement Administration. This story has been on fire since it appeared on the Sunday night broadcast. While the public perception of the message is pretty much one sided


OCTOBER - 2017



against the major drug wholesalers who sought relief from the aggressive tactics of the DEA, there are always three sides to every story. As someone who has had several dealings with settlements for various DEA infractions, I can see that at times the DEA has very powerful tools at their disposal for civil violations of the Controlled Substance Act and those tools carry very stiff fines for DEA registrants. The fines even went higher recently as there was an inflation factor added to the fines so the base $10,000 fine is now pegged at $14,450 per violation and the $25,000 fine is now approaching $60,000. All of us are living with the ill effects of Opioid addiction and the horrific effects it has had on society. We also all must know someone that has lost a loved one to this terrible disease. However, in spite of the drama in the 60 minutes / Washington Post story the DEA has

been very aggressive at times on suppliers and even on shippers. Did you know that both United Parcel Service (“UPS”) and FEDEX were sued by DEA for their respective failure to monitor suspicious orders being sent through their carriers? Wait a minute. Both FEDEX and UPS are not registrants with the DEA so where does DEA come off charging them with such failure to monitor controlled drugs shipped through their carriers? Well UPS capitulated and in March 2013, they settled with the DEA. According to Bloomberg News, UPS agreed to forfeit $40 million to settle a federal probe into shipments for illegal online pharmacies, admitting the company had information it was helping distribute controlled substances. On the other hand, FEDEX challenged the initial findings. In June 2016, Fedex got what they wanted. Yes, on occasion, once in a great while, fighting the government’s what appears to be an unjust prosecution pays off. FedEx’s victory

in a two-year-old lawsuit brought by the Justice Department that accused the shipping company of conspiring with illegal online pharmacies by transporting drugs without valid prescriptions. That’s right—FedEx, the drug mule. On June 20, 2016 U.S. Attorney John Hemann, (who had inherited the case from former prosecutor Melinda Haag), agreed to drop the remaining charges against FedEx. Earlier in March 2016, federal Judge Charles Breyer dismissed most of the 18 charges due to Justice’s sloppy paperwork—attorneys had mixed up FedEx’s corporate-structure titles—and appeared ready to do likewise with the rest. “I know this is a somewhat novel prosecution, but whether it’s a novel prosecution or not doesn’t mean the procedures ought to be novel,” the judge quipped. Judge Breyer warned prosecutors during the proceeding, that “the case is terminated” if they couldn’t produce evidence that FedEx had “knowingly” shipped drugs without valid

Around the PharmacyFrom page 12

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prescriptions (e.g., Xanax, Ambien and Viagra). The judge noted that the Drug Enforcement Administration appeared “unwilling or incapable” of providing a list to FedEx of illegal pharmacies. He also asked why Justice wasn’t prosecuting the United States Postal Service. A very good question to present, why let the USPS get away with their same behavior, (you know why?) the USPS – the Post Office has no money that the government could grab, that is why!!

OBAMACARE 2018 If you cannot kill something directly, you just keep picking away in bits and pieces. That seems to be the strategy for President Trump and the Obamacare health care insurance program. President Trump tried two or three times to have Congress repeal this legislation, but has not been able to muster the votes to get his way. So now what he is doing is chipping away in various ways to destroy the Obamacare insurance market. The access to the enrollment website is being limited to six days a week and the seventh day (Sundays) is going to be used for maintenance—just an excuse —and the advertising budget which is intended to help the public understand the various options which are available will be cut by approximately 75%, in the hope that there are less enrollees in the program for the 2018 calendar year. Additionally, President Trump has announced that he plans on ending the insurance company subsidies which were created to help low income individuals and families in their efforts to find affordable health insurance policies. Many of the Obamacare insurance companies have already anticipated that these subsidies would be eliminated and they have increased their 2018 premiums expecting that these subsidies would be gone. All of these moves just hurt the existing marketplace for people seeking affordable health insurance.

We are not sure how these moves will affect the Obamacare marketplace but the long-term status of this health care program remains shaky at best. I expect the number of uninsured people in the United States to rise a significant number which is contrary to what was the intent of Congress when Obamacare was created.

NECC Update and other Bad News By way of background you may have forgotten the details but back in September 2012, the New England Compounding Center (NECC) com-pounding of sterile methylprednisolone injections was the cause of a meningi-tis outbreak which sickened over 800 individuals and resulted in the death of 76. NECC had been in violation of its state license because it had been functioning as a drug manufacturer, producing drugs for broad use rather than filling individual prescriptions. In December 2012, federal prosecutors charged 14 former NECC employees, including president Barry Cadden and pharmacist Glenn Chin, with a host of criminal offenses. It alleged that from 2006 to 2012, NECC knowingly sent out drugs that were mislabeled and un-sanitary or contaminated. The behav-ior of the NECC pharmacy team con-tinues to drag through the court sys-tem. On Wednesday, October 25th, a Boston federal jury convicted a former pharmacist of NECC of racketeering, mail fraud and other crimes for his role in a fatal meningitis outbreak stemming from a prescription steroid he mixed that was later found to be laden with mold, but acquitted him of second-de-gree murder. Sentencing will follow in due course. The nearly 80 deaths related to the dispensing of contaminated injections from NECC as well as hundreds of patients who were stricken with various serious ailments and mold infections caused the federal government to strengthen the ability of the FDA to police compounding pharmacies as well as the creation of a new level of dispensing non patient specific prepared medications through what

has been created, FDA Outsourcing Facilities, also known under the section of the Food Drug and Cosmetic Act, as 503B outsourcing facilities. Speaking of compounding, a Dallas pharmacy executive has pleaded guilty to taking part in a massive kickback scheme that scammed the military’s insurance program out of more than $100 million, authorities said. Andrew Joseph Baumiller, 38, of Dallas, pleaded guilty in mid-October to conspiracy to commit health care fraud in connection with Trilogy Pharmacy. He faces up to 10 years in federal prison and a maximum fine of $250,000. Compounding is a very tempting way to reap easy profits based on the spread between actual cost and the inflated AWP associated with the raw material. We as health care professionals must remember we have an ethical oath to uphold. Unfortunately, we have some folks that forget that aspect of being a health care professional. Do you like squid? Watch where you buy it. Why, you ask? Authorities in Yucatan, Mexico issued a warning to Yucatan’s fishing industry that an organized group of cargo thieves active in the area has stolen a total of 13 cargo truck shipments of frozen octopus with a total value of $39 million this month. Officials issued the alert after noticing that the number of cargo thefts of octopus had risen sharply beginning in mid-September in comparison to the previous year’s one to two reports of cargo theft of octopus. Armed cargo thieves intercepted the trucks by blocking the road from the port of Veracruz to Puebla as shipments traveled. Who said that drugs were the only thing that are hijacked?

Chain News Walgreens and Rite Aid finally made their proposed merger through the Federal Trade Commission approval process. This deal is not as huge as originally intended and Rite Aid remains a small player when all is said and done. Walgreens, (a division of Walgreens Boots Alliance) will phase in the purchase of more than

Around the PharmacyFrom page 13



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As pharmacists, we know all about PBMs, and we speak “pharmacy payment-ese” fluently. Unfortunately, talking about PBMs and the pharmacy payment system is Greek to almost everyone else. Last month, at the National Press Club in Washington, D.C., NCPA co-hosted a forum, “Principles for Patient Centered Drug Coverage,” with the Center for Medicine in the Public Interest. The attendee list included consumer and advocacy groups for specific disease states. Why? We wanted to share with them the payment “Greek” that impacts prescription access and costs for virtually every consumer and payer. Scrutiny of the enormous control PBMs exert over prescription drug payments has grown exponentially over the last year (thanks in part to NPCA’s efforts). The issue catalyzed during last year’s Congressional hearing on the dramatic price increase for EpiPen, where it was revealed that the manufacturer (Mylan) was only partially to blame for the 500 percent price increase. The other culprit that previously had been flying under the radar was, of course, the PBM. That fact opened the eyes of legislators and reporters. Since then there have been dozens of stories published about how PBMs contribute to the higher costs of prescription drugs. Those have drawn the attention of consumer and patient advocacy groups who are seeing rapidly rising prescription drug prices, patient access limited, and consumers forced to use mail order pharmacies, and are wondering “What gives?” Our forum was helpful in educating many interested groups—outside the pharmacy space—who are still forming their opinions. Thanks to RxPlus Pharmacies, Georgia Pharmacy Association’s Academy of Independent Pharmacy, and Smith Drug Company / Burlington Drug

Company / HealthWise Pharmacy for their support in helping make the forum possible. One of the panelists, Dr. Mark Fendrick, who is director of the Center for Value Based Insurance Design at the University of Michigan, had the right take on the issue of healthcare costs. The discussion frequently focuses on decreasing health care spending, but Fendrick argues the goal shouldn’t be cost reduction; it should be improving health outcomes. Instead of working to spend less on health care, we should focus on spending more, efficiently. He said there are two components to accomplishing this goal: 1) identify, measure, and eliminate services that do not make people healthier, and 2) fund underutilized services. That was one of the reasons for the forum—to find a better way than the current payment model, which puts the 10 percent of healthcare costs spent on prescription drugs in a silo. We need an integrated model that leans on properly used prescription drugs to control overall healthcare costs. In contrast, as panelist after panelist revealed at the forum, what PBMs seem to do best is make money—often at the expense of patients, plan sponsors, and yes, pharmacies.PBM tactics not only fail to make people healthier, but they also can wreak havoc on your business. PBMs use retroactive DIR fees to collect as much as 11 percent of your reimbursement amounts. The National Press Club is known as “the place where news happens.” While our discussions would have been no newsflash to pharmacy owners, the forum was an important step in informing the opinions of non-pharmacy groups interested in a new and better prescription payment system.

- B. Douglas Hoey, RPh, MBANational Community Pharmacists Association CEO

PAtient ADvocAtes & PhArMAcY PAYMent-ese

Many PBMs, Plan Sponsors and state pharmacy boards require that you report any changes or adverse actions against the pharmacy or any employee. Failure to report this information in a timely manner can lead to additional discipline, sanctions or contract termination.One example is Express Scripts (ESI) and their requirement that any changes or actions must be reported to ESI within 5 days. This would include changes in pharmacy phone or fax numbers, emails or addition of new services like LTC or compounding. This also includes any discipline, court convictions or exclusions. Any actions against the pharmacy

or one of its employees must be reported. PAAS has seen several instances where ESI has issued demands for Corrective Action Plans (CAP) from pharmacies that failed to report timely. In one case, ESI was demanding that the pharmacy replace the current pharmacist in charge (PIC) or face immediate termination. If you have any changes or adverse actions, be sure you report those to all plans, PBMs and licensing agencies ASAP. If you are currently working with a PSAO or GPO for your plan contracting, they may be able to assist you with providing updates and notifications.

rePorting chAnges AnD ADverse Actions


INSURANCE COVERAGE FOR NEW ADVANCESA N DT H EL AW

This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and the New York City Pharmacists Society through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

An earlier article in this series talked about preparing to enter the exciting period of change that is occurring in the pharmacy profession. Recent changes in a number of states have broadened the clinical and patient care activities that can be undertaken by pharmacists. These changes take many different forms. Ohio passed a bill that authorizes pharmacists to provide a large number of patient care activities, including ordering and analyzing the results of blood and urine tests, ordering up to a 30 day supply of life saving medication when a physician is unavailable, and modifying drug therapy (including ordering new drugs). Many other states also allow pharmacists to order and interpret laboratory tests. Most states allow pharmacists to participate in Collaborative Practice Agreements (CPA). The activities allowed under a CPA vary tremendously from state to state. These can include initiation of drug therapy, modification of drug therapy and/or discontinuation of drug therapy. Another development is the use of statewide protocols to allow pharmacists to prescribe certain medications. The leaders in this area are New Mexico, Idaho, California, and Oregon, but other states are beginning to follow their lead. Among the medications that pharmacists are allowed to prescribe are emergency contraception, smoking cessation, oral hormonal contraceptives, and preventative prescription medications recommended by the CDC for people traveling outside the US. A question that should come to mind for every pharmacist involved is whether they are covered by their insurance policy for these activities. This is a very important and challenging question because the coverage provided by each insurance company is different. You cannot just assume that new practices are covered. Each insurance company can determine what they do and do not want to cover in a policy, regardless of what constitutes your state’s scope of practice. For example, there are policies available in the marketplace that exclude damages resulting from patient counseling – whether or not the counseling is required by law. Whether the services you provide are required or optional, you will want to be sure you are adequately protected. It is never safe to assume that you have coverage for something that you cannot find in your policy without first asking and validating it with your insurance company. So how do you go about examining your insurance coverage? Remember that under the law, insurance is a contract. The terms of that contract or agreement

are spelled out in the insurance policy. While every provision is important, three parts of the policy are key to our question. They are the definitions, the insuring agreement, and exclusions. Make sure that the activity in question is included in the definitions and/or the insuring agreement of the policy and that it is not included in the exclusions. In a situation like we have in these states, new activities recently authorized likely will not be found in the policy yet. There is a time lag due to the requirement that insurance policies be approved by the Department of Insurance in each state. Because of this lag, coverage will depend on the insurance company’s interpretation of its existing policy language. Some policies carry a broad definition of what activities are covered. For example, the policy may say that you are covered for your acts as a pharmacist or for your acts within the profession of pharmacy. For cutting edge advances, you may not know how your insurance company will interpret what acts they are intending to cover. Another insurance company includes the phrase, “and other services of a professional nature legally performed by “you””. This phrase picks up newly authorized activities until policies can be rewritten to specifically include them in the policy language. It is important to note that the phrase also includes the words “legally performed”. The pharmacist would need to complete any required training program or certifications prior to providing these services for the coverage to apply. It is also important to comply with all procedures and recordkeeping required by the law. Pharmacists will need to verify what activities they are legally allowed to provide in their state. Once they have chosen the activities that they wish to add to their practice, pharmacists need to verify coverage with their insurance company because every insurance company is different.

© Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.

This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.


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most familiar to the legislation (e.g. taxes, environment, health, education, elections, crime). Does he or she chair a committee or task force? You are looking for common ground, a way to start a conversation.

What will be the agenda and timeframe for the meeting? When the meeting is scheduled, ask about the time allotted for the meeting and who on staff (if anyone) will attend. You’ll want to keep these facts in mind. Since you have initiated the meeting, you are expected to present the topic and come prepared for the discussion. PSSNY will provide materials (e.g. talking points, a copy of the legislation, memos of support or opposition). It is up to you to establish rapport and to present the materials in a way that is factual and convincing. If the scheduler offers a meeting with the chief of staff, accept the meeting. Meetings with constituents are always reported to the elected official. Your time will not be wasted.

What are the general rules for meetings with legislators?• Be on time.• If you do not meet with the legislator

directly, do not express your disappointment. The staff person will brief the legislator after your meeting. Be sure to get the card of the person you meet with or get the person’s name, title, and contact information.

• Be prepared. Review talking points, printed materials and documents designed to be left with the legislator.

• Stay on topic. Do not deviate from statements made in printed materials developed by PSSNY.

• Do not negotiate changes in PSSNY’s position or language in the bill.

• If you are asked a question you cannot answer, do not guess. Say you will research the question and get back to the legislator with the response.

• Maintain a friendly business-like manner.

• Provide written feedback about the meeting to PSSNY. Tell us who you met with so we can plan follow up.

• Follow up with a brief note thanking the legislator or staff member for the meeting.

• DO NOT MENTION CAMPAIGN CONTRIBUTIONS.

• KEEP IN MIND PATIENT PRIVACY AND OTHER LEGAL OBLIGATIONS REGARDING THE DISCLOSURE OF INFORMATION.

What should I say in my meeting?• Keep the ultimate goal in mind: A

working relationship based on mutual respect that will be ongoing throughout the legislator’s tenure of office. The legislator should see you as a valuable source of reliable information and an active, engaged constituent.

• Introduce yourself as a pharmacist. State your home address and the name and address of the pharmacy where you practice.

• Establish common ground by mentioning a recent news item, a public event that included the legislator or a fact from the legislator’s bio that suggests something in common.

• Talk about what you do. Describe the neighborhood, the healthcare problems you see, and how you, as a practicing pharmacist, have helped people in the district.

• Present the issue using the suggested talking points and elaborate on them with additional facts and examples from your experience. Leave behind copies of the PSSNY Memoranda of Support or other materials as directed.

• Establish next steps. Is the legislator ready to follow through and vote for (or against) the bill or join on as a co-sponsor? If the legislator is not ready to make a commitment, what other questions does the legislator have? Offer to follow up and/or be available for another meeting.

With your help, PSSNY can build a strong network of voices that will be heard loud and clear in Albany. Hope to see you at our Mid-Winter Meeting at the Desmond Hotel, Albany New York, January 26-28th 2018. - Kathy Febraio, CAE

PSSNY Executive Director

Message from PSSNYExecutive Director From page 4


Processing credit cards with phone lines is like surfing the Web using dial-

up. Would you buy a new computer, connect it to the Internet via dial up and expect an enjoyable and reliable browsing experience? Modern websites are so content rich that dial up connections struggle to get the job done. Processing EMV credit cards through a phone line is a similar idea. Analog phone lines, also known as plain old telephone systems (or POTS), are simple and use an electronic signal to transmit sounds but they are limited in the amount of data they can carry. Digital phone lines transmit more data but the signals are in binary code (i.e., zeros and ones) and the receiving device reassembles that code back to the original signal. Digital lines are great for phone calls, but not so great for transmitting credit card data. The Retail Council routinely receives calls from frustrated business owners who have been using the same analog or digital phone line for years and suddenly receive errors like AP dupe, no line, comm error, critical batch error and more. Broadband has become the preferred way to transmit data while surfing the web or transmitting card data. It is often less expensive to use a broadband connection than to pay for an additional dedicated analog line. Telecommunication companies are working to bring broadband to their customers, though some rural areas only have access to analog phone

lines. The Retail Council offers mobile readers for smart phones or tablets, and wireless terminals that run on 3G as alternatives for merchants with phone line issues who are unable to get a broadband connection. The checkout is your customers’ final interaction with you before they leave your store. Call the Retail Council if you have any questions about upgrading your connection so you can ensure the final step of your customer experience runs without a hiccup. “Our credit card terminals ran well on our digital telephone lines for years-until one day they didn’t. It started with an AP dupe or a declined card every once in a while, then batches would occasionally fail. We assumed our terminals needed to be reprogrammed and then upgraded, so we did that… they ran well for a while and the same issues would start again. This became incredibly frustrating to the staff and the cardholders. We would spend hours on the phone trying to troubleshoot the issues and to make sure our clients were charged correctly. We had the internet at our practice, so Nicholl recommended we switch from the phone lines to an IP connection. The switch was as easy as getting a new cable and pressing a few buttons and I wish we’d done is sooner! The processing time is so much faster and we haven’t had a single issue since the day we pulled the phone cord.” - Donna Pontrelli, Franklin Lakes Animal Hospital

DiAl uP DrAMA

understand that it may be because of your dispensing of opi-oids. If they say that the inspection is a “Routine Inspection”, any violations of required records, security, your due diligence policy especially the front of a prescription will be their focus. At this point, you should be asking yourself, “Are my DEA records organized?” or “What would happen if my DEA re-cords were not organized?”. If they were disorganized, DEA will tell you that failure to maintain complete and accurate re-cords will cost you $14,739 per violation. If your DEA Forms 222 or your Schedules III through V invoices don’t note “quan-tity received” and “date received”, you are violating DEA reg-ulations. Other records that will need to be presented and readily retrievable are your DEA biennial inventory, your DEA Forms 106 for theft or loss of controlled substances, Power of Attorney letters, destruction records, expired drugs inventory, etc. If you still accepting hard copies of controlled substance prescriptions, you need to make sure they have all the re-quired information on the front of the prescription. Please un-derstand that the prescription information must be written on the prescription. The prescription label is a secondary record, and it should ONLY be placed on the back of the prescription. Labels with the patient’s address is not acceptable by DEA,

the State Board of Pharmacy and the PBMs will take your money for the failure to maintained DEA required prescription information. The civil fine for these violations is $63,523 per violation. If they fine ten prescriptions with no address, the maximum civil fine will be $635,230. Now that I got your attention, I’m giving you this free ad-vice. DEA has now linked the use of Heroin with the abuse of opioids such as Oxycodone or Hydromorphone and the deaths relating to such drug abuse. It appears that their target is the prescriber but in many cases the pharmacy that dispense such controlled substanc-es is also on their cross-hairs. If you don’t dispense these drugs the chances of you being their target are lessened than those that do dispense those drugs may be in the cross-hairs of a DEA inspection. Remember DEA will look at your required records, se-curity of controlled substances, and the pharmacist corre-sponding responsibilities along with the pharmacy DEA due diligence policy. If you want to read the federal registrant go to your search engine and note,” federal register Vol.82, No.22 / Friday, February 3, 2017 / Rules and Regulations” and look for pages 9131 to 9136. Be safe and be careful. The DEA is ready to deplete your checkbook if you are found to have any significant DEA record keeping violations.

~ Carlos AquinoFounder and President PharmaDiversion LLC

©2017 Carlos Aquino all rights reserved

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Inappropriate use of the comment field. ISMP has received numerous error reports when the field for “comments” or “notes” in the electronic prescribing (e-prescribing) system was used to clarify a medication order. According to a recent error report from a long-term care facility, a nurse received a telephone order for a resident to receive warfarin 1.5 mg daily. During order entry, the nurse chose warfarin 3 mg tablets, intending to include directions to administer a ½ tablet daily. However, the nurse accidentally selected 1.5 tablets instead of 0.5 (½) tablets, and the final entry of the order read “warfarin 3 mg—Administer 1.5 tablets daily.” In the special instructions section of the entry, the nurse tried to clarify the order by entering, “Administer 1.5 mg daily.” Unfortunately, the pharmacy dispensed 4.5 mg per dose, and the resident received 2 days of the three-fold overdose (4.5 mg), resulting in an elevated INR and risk of bleeding.

We have received similar reports from community pharmacists who have received electronic prescriptions (e-Rx) from prescribers who include two different sets of directions, one in the sig field and another in the notes field, in the e-Rx. For example, a community pharmacy received an e-Rx for the anticonvulsant gabapentin with “1 tablet PO TID” in the sig field but “i po bid x7 days, then i po tid thereafter” in the notes field. Using the comment field to correct electronic orders is problematic. Often, the pharmacy does not see the information in the comment field because the interface may not properly transmit it to the pharmacy system or it is displayed apart from other dosing instructions. Staff and prescribers should seek assistance if they cannot enter the correct dose or frequency into the e-prescribing system, rather than relying on the comment field to correct the problem. Direct communication with the pharmacy may help prevent confusion and error. We ask that pharmacists communicate with prescribers and facilities when potential or actual errors are encountered with the systems they are using. We also ask that all healthcare practitioners continue to report actual errors, close calls, or hazardous conditions related to e-prescribing to our medication error reporting program at: www.ismp.org/merp. We will continue to share reports that we receive in our newsletter and communicate with vendors and others who may be able to effect change in safe electronic prescribing. Do not cover manufacturer’s barcode. In an ambulatory care pharmacy, XARELTO (rivaroxaban) 10 mg was dispensed instead of VESICARE (solifenacin succinate) 10 mg. The error was missed during the final verification process. However, the patient realized the error prior to taking any doses. One root cause of the error was that the barcode on the manufacturer’s label was covered by a pharmacy-applied label and, therefore, not available to be scanned. It should go without saying that pharmacy staff need to ensure that price stickers or other pharmacy labels or markings never interfere with ability to scan the manufacturer’s barcode. A best practice is to periodically review current inventory and completed prescriptions to confirm manufacturer barcodes are visible for scanning.

MeDICATION SAFeTY • PReveNTINg eRRORSBy the Institute for Safe Medication Practices“Have you experienced a medication error or close call? Report such incidents in confidence to the ISMP National Medication Errors Reporting Program (ISMP MERP) at 1-800-FAIL-SAF(E) or online at www.ismp.org to activate an alert system that reaches manufactur-ers, the medical community, and FDA. ISMP guarantees confidentiality of information received and respects reporters’ wishes as to the level of detail included in publications.”


1,900 Rite Aid drug stores which is a much smaller number of pharmacies than originally announced. Walgreens agreed to reduce their purchase by about 250 fewer stores from Rite Aid than it had previously planned to acquire. This is the result of discussions with the Federal Trade Commission and is part of a revised plan that has received overall regulatory approval after multiple previous deals had flopped. Walgreens confirmed that it had received the government’s sign-off to take over 1,932 Rite Aid stores and three Rite Aid distribution centers. Now word has just come out that because of overlapping locations, Walgreens plans to close about 600 drugstores

as it completes the $4.38 billion deal to buy the pharmacies from Rite Aid. As we go to press, we are not sure where the closings will occur but almost all of the closings will be Rite Aid stores, and the vast majority will be within a mile of another store in the Walgreens network.

Politics in America Today Washington seems to be in a state of turmoil. We have fighting on both sides of the isles in the Senate and there seems to be a new level of gridlock. We go to bed wondering if we are going to war with North Korea. We are confused as to health care reform. Will we get tax reform? We don’t know what to expect from the new presidential administration. Investigations abound as to the Russian

connection and climate change is fake news. We are truly living through unusual and uncertain times. Now more than ever we need to get out and vote in the November election and in all elections going forward. We need to also get involved in the democratic process which means keeping in touch with your elected officials on all levels, municipal, state and federal. Many people do not even know who their elected officials are. Remember they work for you and me. We pay their salaries.

Folks enough said for this month. Stay well stay informed and please stay involved. ~ Jim Schiffer

©2017 James R. Schiffer

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NEW YORK CITY PHARMACISTS SOCIETY How To Survive A · NEW YORK CITY PHARMACISTS SOCIETY President’s Message VOLUME 26, ISSUE 7 PSSNY hELPLINE 1-800-632-8822 OCTOBER 2017 The Voice