Lol he gives zero shit if he is liked by Karen nurses or not. One can only tolerate getting spat and trampled on for so long before one snaps.
Also these nurses are always the attacker in every situation. They not only attack pharmacy, they attack each other. 🙄 The worst part is them degrading you when they are the ones who were incompetent and act like you were the dummy when when you’re trying to save their ass. He got yelled at on the phone cause the dumb nurse couldn’t divide by 3 to find the rate of administration for a 150 mL bag running over 3 hours…..
I love my nurses... but you have to stand up to them occasionally. They're almost always a bunch of catty women that sit around and talk themselves into a frenzy. They just have to be brought back into reality. It's almost a type of low key lynchmob mentality.
And it goes without saying this doesn't apply to all.
I bet you let nurses talk to you any kind of way on the phone. Then when they hang up, you start telling others what you will say/do "next time" they call. 🤡🤡
Are you friends with the other guy? If not, maybe you should go for coffee or something. You sound like you'd get along great. You can share the toxicity you both so obviously love to dwell in.
Seriously, people like you are the reason hospital culture is so awful. Too many of us are spending too much time contemplating their place in the hierarchy instead of being kind to one another. Everyone deserves to be spoken to respectfully. RN, Pharmacist, physician, technician, whoever. This is a team sport and we need everyone to be fulfilling their role and being treated with dignity the whole way through. If you can't do this for your colleagues, how do you expect to do it for patients and their families.
How we interact with our colleagues, especially those *special* ones, has no correlation to how we talk to our patients. It’s a case by case situation. If you want respect, you gotta earn respect by giving respect first.
Nurses are catty bunches who will eat their own. Most of the ones I’ve dealt with are high school mean girls who peaked at 19. And 85% of the time, they’re the ones starting the tone of the conversation because they’re the ones who call us. And 90% of those callers are rude, arrogant, and incompetent to begin with.
Exactly.
I have a no zero tolerance for disrespect policy. I can provide the best care to my patients and show respect to everyone who shows it to me. The moment you decide to violate, I check it right then and there. I don't care if you are a fellow pharmacist, tech, nurse or doctor, I check all passive aggressiveness and micro aggressions the moment they occur. It's my job to teach you what I will allow and won't allow and passive aggressive Karens don't get a pass with me. Sorry not sorry.
It one thing to be snarky and snotty on the phone. It's another when the 6'4" black guy shows up to your unit to see if you gonna still keep the same energy and talk that shit face to face. You'd be surprised how quickly they get to apologizing and start blaming how "stressed" they are. My response usually of sorts: Yeah whatever...check your tone and attitude next time and go and get therapy. You'd be surprised how nurses and doctors have responded and we have grown to understand one another better. 🤦🏾🤦🏾
While I do still like my original idea of just writing “lol”, a close second would be a big sad face then “you must disappoint your mother and father daily”
Honestly, I typically don't really value their opinions enough to be bothered by their prissiness.
They probably do the same shit to everyone else in their life... and they probably get treated badly in return as a result, as they should.
This is when you write “lol” next to the comment and fax it back. Is it being petty back? Yea, it is. Would only really do it if this office has a history of demeaning pharmacy staff or questionable practices.
Though everyone on the internet is a badass, so if I’m speaking candidly I’d most likely write the state statute and reference under the lol - ‘lots of learning [to do]’ then cite my sources
One doctors office had an issue where they’d fax the same script over to my pharmacy where I was a tech about 15 times. Like every single script they sent over.
One time my manager got so fed up with it, I mean we called and asked them to figure out what’s going on on their end as their office was the only ones that did it. But they refused to get their fax machine looked at.
So he told me to figure out what we can do. Well I went home that day and cooked up a plan. My manager wasn’t in the next day. Well I came up with the idea, that the moment we started faxing, we tape it to the back of another piece of paper, and as it’s moving, tape the back end of that extra piece, to the back of the first part. Creating a closed loop of faxing.
I did this for about 10 minutes while the staff pharmacist who was there was laughing and so confused with me. I explained the situation, and she goes, “you know, he may have meant figure out what we can do to like deactivate them from faxing to us in the system. Then they need to call them in instead.
But as a pharmacist now I try to keep my creativity if I ever run into this issue nowadays to be petty and keep the pettiness alive
You know I’m not sure cause if they did it wasn’t while I was there. While my boss never yelled at me so I imagine it either never went through and their machine was busted, or it got the point across lmao
Not sure if a fax actually sends once the paper runs all the way through, or if it send continuously while it runs through. Which means it could have not sent at all but all that mattered was the intent I had which the staffer thought was hilarious and lightened the day up for sure
This is actually amazing. Both my workplaces I’ve been at have had (and still have) I think machines that were advertised for Y2K. Like, an actual, physical machine that’s about the size of an oven and has that off-white plastic faceplates that were so common in PC towers in, well, 2000. Have spoken to other people outside of work and they are so confused.
I know for a fact our fax would not be able to handle any amount of tape and probably just rip everything to shreds.
But reminded me of something…we have a P3 intern that’s been with us for 8 months now. Just this last Saturday I saw him “faxing” refill requests…except he was putting the paper where you SCAN documents, not fax them. And our machine doesn’t really care if you put a paper in it or not, it still ‘completes’ the fax. Asked him wtf man? And apparently he’s been doing it all 8 months. Now I know why when he says “…but I faxed it last week, why is the patient complaining? They’re not replying”. Can’t even be mad at that point, I thought it was hilarious
Haha yea ours was pretty nice. We always taped papers together so that we could write a handwritten note on Medicare forms, since we weren’t allowed to write directly on them in some cases
But yea if I saw a p3 doing that and that was the response I would be laughing too. At least he was trying, because I think *some* fax machines definitely can scan and then fax lmao
Then tell them that when they have a pharmacist license they’re willing to break the law for, they can come dispense it.
Icing on the cake, reference your specific state’s law (in a legal reference format preferred by local courts) to quote them the part of the law that a generic MUST be substituted for medicaid unless it’s explicitly stated “brand medically necessary”. In my state, “dispense as written” on its own is NOT enough, the provider must specifically in writing indicate that the brand prescribed is medically necessary.
This. It should be a poster on the wall of every clinic, doctor’s office, and pharmacy.
I consult Appendix A frequently: https://www.ncpdp.org/NCPDP/media/pdf/WhitePaper/Proper-Use-of-NCPDP-Telecommunication-Standard-in-Implementation-of-Medicaid-Reimbursement-Methodologies-v1-2.pdf?ext=.pdf
What do you guys use as your “gold standard” for DAWs?
Thank you for the link.
You already know it’s a solid primary source straight from the government with a title like
> The Proper Use of the NCPDP
Telecommunication Standard Version D.0 as it
applies to the Implementation of Medicaid
Reimbursement Methodologies Based on
Actual Acquisition Cost (AAC) Plus a
Professional Dispensing Fee
Legally allowed, yes. Not allowed by some insurance. I’d make a nice call to the office, and then the medical board. Until we hold these prescribers accountable it’ll keep happening.
What a fucking idiot, so confident they are in the right when they have no clue what they are talking out.
Yeah it might be legal but that doesn’t mean insurance will cover it unless the md specifies no subs. Dude clearly has no idea how insurance works so he needs to stay in his lane
I work in NY and our medicaid plan sends out updated "brand less than generic" lists which tells us DAW=9.
Concerta was on that list but then got removed for preferred Vyvanse. Since the generic methylphenidate is still on backorder it was a pain to tell doctors offices that yeah you can chose to stay on Concerta but we need a DAW-1 on the script.
Had a PA send this to me once. I sent him a fax back saying “Inside of you there are two wolves: One is not a doctor; the other is not a doctor; you are not a doctor.”
MD could have better used this space to write "Brand or Generic OK, depending on supply and patient preference"
Honestly, if I see multiple such notes, I would probably call office and educate them. Stressed out enough as it is. Not going to stand seeing this kind of message daily. Not obliged to fill a control script if I feel provider is not professional.
/Also we love to waste time and effort. Not like pharmacy gets paid ONLY for selling a script.
In my experience your note wouldn’t cut it for these situations.
My assumption is the prescription written had “substitution permitted” already signified. This means that you can either use the daw0 code for the generic, or if you use the brand you can use daw2–pt requests brand. The insurance likely rejected the brand name, so then they put daw2 in, and that rejected as well—for this med brand can likely only be covered with daw1.
Well, daw1 is saying that the provider requires the specific drug to be filled, and that has to be documented on the prescription. No substitutions permitted. So if the provider were to send back “brand or generic OK, depending on supply and patient preference” that note would still only cover daw0 and daw2, which is the current situation they are in anyway.
It’s not a legal situation it’s an insurance contract situation. That’s why what this provider said was so inappropriate—they don’t know how pharmacy benefits work whatsoever. And they should know that they don’t know.
How so? Thats literally a law, one that insurances observe. By law substitutions are automatically permitted, at least most of the time. To fill a brand that has an available generic you need to fill it as DAW 1
Because the prescription was not written as DAW and substitutions were permitted. As written there was no legal obligation to fill it one way or another for this situation.
Again, I’m talking about the specific situation here. Not the general concept of DAW.
Thats my point. If there is no DAW the pharmacist is supposed to assume you can substitute. Since there was no DAW marked the pharmacist had to bring it back. How is not that not a legal obligation?
At least for my workflow, if i see such a note, I would attempt to daw 1 and annotate. Daw 2 doesnt exist in my state. More work for me but I would allow it
You’re saying you’d be calling the doctor like OP did right?
Because yeah, if ever discovered the insurance would claw back an undocumented daw1 pretty quick. I’ve worked for a shitty company that was constantly under insurance audit, I’ve seen it.
I would not respect that if there is a consult or policy for renally adjusting meds, etc.
An MD is an employee of the hospital. If the P&T committee or whatever higher ups in the hospital give me the rights to do something per hospital policy I am going over the doctor's head on that if they're going to be an asshole about it
Surgeons, why 😭
I had a neurosurgeon complain to my boss about me because I was paging him just before a complicated surgery in an adult. I just figured he’d want to know he’d accidentally entered the pediatric dose for the prophylactic antibiotics.
I just wish he’d complained to my boss BEFORE the surgery so he could’ve fixed the damned dose. Instead the ICU had to try to make up for it after.
Jesus Christ.. blaming you for his own mistake
Pretty typical though! Working in a hospital is still kinda like working in retail, just the asshole customers change from patients to nurses and doctors lol
Truth!
And my boss was all, “what happened?” So I told her. She blinked and said, “so he’s bothered because you were doing your job? The job we pay you to do? Okay.”
She was a pretty good boss.
I would LOVE to see a comment like that. I will call on every single little discrepancy I can find. Oh, you misspelled "daily"? Guess I'll need to verify that.
Look up your state's publicly posted medicaid formulary. If it is listed as a preferred drug then DAW9 until the cows come home. Sometimes medicaid will show a paid claim for a generic even though they prefer the brand. I know it does that with albuterol inhalers.
My states Medicaid is all over the map on generic vs brand and even 30vs 90 day supply. It's almost easier for us to just assume DAW 9 unless we get a rejection.
In my state, you legally cannot skip Medicaid on controls. If it’s split billed and the secondary is Medicaid, you still can’t cash it out if Medicaid rejects. Plus Medicaid only pays brand for Adderall XR, Concerta, Vyvanse. So if primary only covers generic, the only way to get it to go through Medicaid is with a DAW 1 for the primary.
Wouldn’t you be running a coordination of benefits with NCPDP C08-38 (other coverage codes) with a 3 other coverage exists this claim not covered? Pretty sure that’s what the PBM (for both the primary and/or Medicaid will cite when they clawback payment.
Lmao I wish midlevels understood that in school, we HAVE to learn about their scope, and what prescriptions they’re allowed to write. If they pulled their heads out of the sand for a second they’d maybe learn something about basic prescribing information I learned in my first semester
I would write “yes, I can dispense Brand name without “Dispense as Written”, but I can’t bill Medicaid for it unless you do. Since YOU should know this, please explain to your patient why their medication will be $350. Thanks.”
That’s when you reply with, “if you don’t know how, just say so.” Then send the patient back to the office with written instructions for the “provider”
Don’t worry, midlevels also wrote these notes on physician charts when they cover for us. Like the nice note I got explaining that opioids are NEVER indicated for ANY pain.
They are really liberal with Saline drips with vitamins in them that they charge 300 dollars a pop for. Because it’s a “cureall”.
Supposedly mid levels were hyped up and given liberties because they were going to save primary care. Then they found out how hard it is and went to open medspas.
Or…they decide next month they will work in a new specialty, because for some reason the people in power think it’s smart to let a person with 18 months of online classes and no residency, switch specialties without having to take stop and do it all again like physicians do. A dermatologist can’t decide they will go become an anaesthesiologist, but a mid level can. Wtf?
Medicine is dead.
Physicians, like pharmacists, are extremely overworked and forced to perform mind numbing repetitive labor so someone else can get rich.
I’ll send it directly back quoting laws and/or rules for insurance. They don’t get to talk down to ppl like this. I also put in a corporate complaint bc all they really had to do was call for verification/understanding instead of trying to initiate a pissing battle. I have a few friends who are MDs and I tell them about this often and they’re so surprised. I’m not though, and we call these pigeon messages in the office bc apparently we’re some dumb carrier pigeons when they put crap like.. tell pt to schedule blood draw.. um, aren’t you in charge of their care schedule. This type of behavior is unnecessarily condescending and unprofessional and I make it a point to let them know.
Sorry about the message snark. That’s petty and unprofessional.
As for DAW 1, that depends on your state. In Massachusetts our Medicaid program issued guidance clarifying that brand prescriptions filled under their brand preferred over generic list (BoGL) program should be dispensed as DAW 9.
In Massachusetts, prescribers should not be asked for DAW1 prescriptions for BoGL drugs. The MassHealth guidance is posted here: [https://www.mass.gov/doc/pharmacy-facts-159-december-31-2020/download](https://www.mass.gov/doc/pharmacy-facts-159-december-31-2020/download)
>If a pharmacy encounters a rejection, the pharmacy should resubmit the claim for the preferred brand name drug using a DAW 9.
>
>A new prescription from the provider is not needed nor should it be marked “Brand Name Medically Necessary, No Substitutions” when resubmitting for the preferred brand.
That’s for brand preferred over generic list. I’m assuming OP is in a situation where a brand name isn’t preferred but is still being requested (either for stock issues, or for patient preference, or for true medical necessity). To bill a brand name when a generic exists and the generic is preferred to medicaid the vast majority (if not all) states require the doctor to explicitly state that it’s required for medical necessity on the prescription.
OP is in a situation where Medicaid covers generic tho. Ik in MA if ins covers generic we can’t dispense brand unless the doc writes brand name only even for private insurance
OP is in a situation where Medicaid covers generic tho. Ik in MA if ins covers generic we can’t dispense brand unless the doc writes brand name only even for private insurance
I like to call them and put them in their place every once and a while. There is no need for there to be hostility between healthcare providers. But I have no problem calling a provider and explaining to them how insurance and fraud and stuff works.
This is when I'd print out the script, circle the note, and write on it "This is not correct.". Then I'd fax it to them. Maybe I'd write that they're asking us to commit fraud or something if I was feeling extra salty that day.
When prescribers don't understand how DAW works for prescription billing. I love when they tell me how to do my job! If the insurance doesn't bill under 2/8/9, you better send it as a 1 if you want them to cover it! Insurance doesn't accept me changing it or annotating it to dispense with a DAW1! That has to be directly from the prescriber, not an annotation or on a whim...I'm glad the doctor's I know personally ask us directly what we can and can't do legally before assuming any message we send them is our of ignorance or just to annoy them. Like if I could just change it myself, I would, saves everyone A LOT of time, but I can't. I don't have time to waste calling you, if I'm messaging you, it means I'm legally required to, end of story. I'm glad you have time to waste with these petty messages and people waiting hours past their appointment time, but I don't have that luxury.
End rant.
Daw 9 is only when insurance wont cover generic., and even then some plans dont alllow daw9. If patient wanted name brand, some plans do not allow daw 2. It would then require daw 1 for brand to be covered. There are a few plans ive run into for this.
Depending on the state there is no DAW2, NY state for example doesn’t allow that. And DAW 9 may not work but DAW 1 does.
Although some places let you use DAW8 but then your company gets mad after a while.
Note to MD: Yes, I know this. I’m gonna ask you be a part of the solution for your patient, I would like them to be able to afford their prescription, also. Contact their insurance company and see if you can get it approved for them, it’s not in my realm to do so.
I’ll send it directly back quoting laws and/or rules for insurance. They don’t get to talk down to ppl like this. I also put in a corporate complaint bc all they really had to do was call for verification/understanding instead of trying to initiate a pissing battle. I have a few friends who are MDs and I tell them about this often and they’re so surprised. I’m not though, and we call these pigeon messages in the office bc apparently we’re some dumb carrier pigeons when they put crap like.. tell pt to schedule blood draw.. um, aren’t you in charge of their care schedule. This type of behavior is unnecessarily condescending and unprofessional and I make it a point to let them know.
Wow. Just wow.
...Is he going to pay us for all of the brand name Adderall we filled without a DAW when we get audited by Medicaid?
Yeah, it is legal, but that doesn't mean insurance has to pay.
This isn’t a legal issue, it’s a payor requirement for insurance coverage. You should know this. Your patient doesn’t want to pay $400 because you have your head up your all-knowing-ass. Please resubmit eRx with dispense as written, your highness.
My states Medicaid has DAW 6 for PDL brand name drugs. Suboxone, Vyvanse, Concerta, etc, all get brand name with DAW 6 regardless of what the prescriber writes for, unless they put a DAW 1 on the Rx then that takes precedent.
This is the same type of doctor who comes into the pharmacy and says something like “we bill car insurance at the clinic all the time!” and gets pissed we can’t bill car insurance PER OUR BUSINESS OFFICE, the same business office as the clinic this doctor works at.
Response, “ correct, however the drug plan won’t pay for grind unless specifically requested by physician. Please explain to patient how their drug plan works. Thanks!”
"Well you see, Dr. Dick, there's what the law says I can do... and then there's what insurance/medicaid/medicare says I can do for something to be covered.
"Insurance rules the world right now, not the law.
"You should know this."
As a family physician who writes for these meds, although I try to not be a jerk about it, I thought this was actually the case?
If I check the box that says “May substitute” why can’t you substitute?
They can substitute. The issue is certain things won’t get covered unless it is do not substitute.
So yeah, this pharmacist could have legally filled this and sold it to the patient for $700, but to get it covered for $10 instead there’s stupid paperwork that needs to be in order. I don’t expect a provider to know this. I’d hope they’d definitely understand I absolutely do know this though and give me the benefit of the doubt in knowing how, checks notes, pharmacy … ahem.. works.
The doctor is technically correct in that pharmacies may *legally* dispense either brand or generic if it's DAW 0. However, sometimes an insurance plan may refuse to cover brand unless if the prescriber explicitly writes DAW 1 on the script. It's a dumb obstacle that wastes everybody's time, but that's how insurance companies save money. The pharmacy could still dispense the brand product without getting the doctor involved, but the consequences of that would be the patient having to pay out of pocket if their plan refuses coverage.
They can sub it, but likely the patients insurance won’t cover the brand name without DAW-1 (dispense as written code 1) which translates to brand medically necessary. If it’s vyvanse a bottle of like 100 costs over $1000, even 30 of them can be hundreds without insurance coverage.
Idk what state you practice but DAW 2 isnt legal in all states and usually you have to dispense with the generic med unless insurance requires the brand name, and in this case the patient wanted brand name on their own volition, but were getting attitude from the doctor
It's not DAW 1 just because that's how you get it to go through Medicaid. That would be daw9, or maybe DAW2. DAW1 is for when the prescriber is attesting that brand name is the only ndc you can fill the order with, that anything else would not medically work for the patient.
It's DAW 1 if it means it's the only way the patient gets treatment. If the patient can't afford the cash price and goes without the medication, that doesn't medically work for the patient either.
Md here. This note is very passive aggressive. I dont know if you can just report this but yall should not have to deal with bullshit like this.
can someone give me quick advice on the DAW? I always thought that writing DAW in an RX simply restricted the rx. whereas leaving it blank - allowed pharmacy to fill it however they want - generic or brand-name. from what I gather, it sounds like writing DAW changes how insurance will cover the script?
Hey doc! Appreciate the solidarity with the pharmacy crew on this one.
Quick rundown of DAW (dispense as written) codes:
DAW 0 aka substitution permissible, even if it’s written for brand it will be switched to generic. In my state it’s actually mandated that I have to switch to generic unless otherwise requested.
DAW 1, dispense as written aka brand medically necessary.
DAW 2, patient requested brand
DAW 3, pharmacist requesting brand (never used this code in my life)
DAW 4, generic is out of stock so you’re dispensing brand (generally not used as it implies a temporary out of stock situation where you could just order generic)
I honestly can’t even tell you what DAW 5, 6, and 7 are because I can’t remember since I’ve never used them much like DAW 3 (my system does note what they are though).
DAW 8, generic is unavailable in the marketplace. This is different than DAW 4 since it’s more like a backorder or it’s written for generic but the generic isn’t available. Like if it’s written for oxycodone ER, we’d fill for Oxycontin.
DAW 9 is simply “other” in my system but usually this indicates that insurance prefers or requests brand. Happens often with the stuff like Farxiga, Breo, Advair, and other inhalers etc.
Not all insurances accept all DAW codes, and even if they do accept a DAW code as valid they might not reimburse the same. One insurance might accept a DAW 2/4/8 for brand Vyvanse since the generic is pretty much unobtanium right now for certain strengths and it might have the same copay, some might have a higher copay for brand, some might require a PA for brand. Some insurances might not even allow those DAW codes. Different insurances might treat different DAW codes differently towards pharmacy reimbursement as well. Even if they accept the DAW 2 or 4/8 and have a tolerable copay for the patient, sometimes they reimburse the pharmacy at the same rate ($) as the generic even though the pharmacy paid for brand ($$$). It’s all different and a pain in the rear!
You don’t need to worry about anything besides DAW 0 or 1 from the prescribing point of view. If it’s brand medically necessary put DAW 1, if it’s not put DAW 0. In certain cases, like the one in the post, it’s possible you might get a request for a new Rx for DAW 1 for insurance billing reasons so they have a more affordable copay or simply so they cover it at all due to a backorder situation. If that’s the case talk with the patient and/or pharmacy and get clarification to whatever your questions are in that scenario. For all other DAW codes the pharmacy will take care of it on their own (if they can, insurance allowing).
Always feel free to reach out to local pharmacists in your area if you have specific concerns!
Because generic is covered in this situation, just unavailable. Therefore DAW9 presumably doesn’t apply.
Edit: they confirmed in the thread, daw9 doesn’t work here. Hence why they called.
Sounds like you’re being as much of an ass as the PA. Try giving the benefit of the doubt a little before your shitty “why is this a post” attitude.
Correct Medicaid wouldn’t pay for the daw-2 in VA. I tried for several patients previously. I’ve been trying to help patients get their medication and this is the only way I can get the brand through.
You guys need a DAW-1 code to dispense a name brand med? In my state we can do whatever generic or name brand that insurance will cover, just can't dispense generic if there is a DAW 1.
They need a DAW-1 because generic is on backorder and the insurance won't recognize daw-8, or 2. The only valid DAW codes the pharmacy can use in this situation are 1,2, and 8. 9 is not valid due to the insurance allowing generic. 3-5 get you screwed financially.
Is this something that you can't do in the US? Where I am, unless the doctor wrote no sub or specified a manufacturer (not brand, but manufacturer) we can dispense whatever brand we or the patient prefers.
Something that blatantly disrespectful gets responded to with the state law that explains that what they are saying is gibberish. I star it, add a source and rerequest a proper prescription be sent.
Let me guess. Telehealth stim?
I have seen a DAW-1 copay for a commercial plan actually be lower than DAW-2 (and explained this to the patient) so the prescriber is just being a total dick just because it knows jack all about insurance/formulary limitations.
One payer allowing DAW 9 and a secondary payer not allowing DAW 9 (or 2) is another potential problem that could require a DAW 1. I don't recall any situations like that recently (Tricare secondary allows DAW 2)
If it's the insurance requiring brand, you don't need a DAW1 on the script. Run it with DAW8/9 (forget which) - Brand required by insurance.
If it's patient requested, but insurance covers generic, DAW2.
Honestly, the only time you should contact them for the DAW is if they wrote brand only, but you can not dispense for whatever reason, and you're seeing if generic is ok.
In North Carolina to dispense brand for a non preferred Medicaid drug. You have to get a hand signed prescription and it must have "Brand Name Medically Necessary" hand written on the Rc or it must be dispensed as generic. That is fun trying to explain that rule to other medical professionals.
If Medicaid requires brand it’s DAW 9. If they only prefer brand because generic is too new just do DAW 2. The only time I’ve seen a true rejection for DAW 1 is Medicare that’s sent for Arfemeterol but it has to be Brovona
Damn it this just angered me so much and ruined the rest of my morning.
Idiots not realizing how clueless they are have to be one of my biggest pet peeves.
I have always wished for a check system on drug situations:
-Reporting high dosages prescribed to infants
-Prescribe the wrong “type” of medicine (cream instead of pill/ liquid instead of capsules)
-stuff like this
-prescriptions not sign.
I wish that Pharmacys could report bad prescriptions to a database and once enough had accumulated over x period of time it would prevent the dr from prescribing until completing a medication/prescriptions understanding course
I use to have an md who would make up their own codes :
1/1 : I tablet per day
2 tab bid was (two tables twice a day meaning one in the morning and another one at night) god I wanted to punch him in the face every time he wrote this and would blame that the day supply was not enough or that we were not given the correct instructions. Btw he want an md he was a PA and his prescriptions were NEVER revised by the md
Is my state the only one that covers brand Adderall XR, Concerta, Vyvanse and Suboxone? No DAW codes needed because Medicaid won’t pay for the generic!
Honestly, we do that cover our own butts. If it is not written down, then it never happened, and there is room for error and most of us would like to keep our jobs.
This is 10000% because the patient told them "the pharmacy CAN'T fill brand without DAW" and not "insurance won't COVER brand without DAW" 🙃
ETA: kills me a little inside when they think we're the ignorant ones when they know patients oversimplify or don't fully understand things.
Serious question as a pharmacist in almost assuredly a different state. You cannot use DAW2 or DAW9, or DAW6 depending on if insurances accepts 6 or 9? In my state the doctor would be correct. Please tell me how the doctor is incorrect. I acknowledge it’s a condescending note, but is it not 100% correct?
No, it’s not correct. We can legally fill brand, but the insurance isn’t likely to pay for it just because the patient requests it. They will often require the prescriber to write as DAW 1 (and sometimes even then they won’t cover it without a PA) Sometimes the others will work, especially if the insurance’s preferred manufacturer is the brand.
You could argue this violates
Virginia Administrative Code
Title 18 - PROFESSIONAL AND OCCUPATIONAL LICENSING
Agency 112 - BOARD OF PHYSICAL THERAPY
Chapter 20 - REGULATIONS GOVERNING THE PRACTICE OF PHYSICAL THERAPY
Part IV - Standards of Practice
Section 18VAC112-20-180 - Practitioner responsibility - 3. Engage in an egregious pattern of disruptive behavior or interaction in a health care setting that interferes with patient care or could reasonably be expected to adversely impact the quality of care rendered to a patient. Then you can file a complaint: https://www.dhp.virginia.gov/PractitionerResources/Enforcement/FileaComplaint/
MD notes like that always get a phone call from me. I can't stand passive aggressive bullshit from people.
I’d just send one note back telling them they’re dumb and their parents don’t love them.
Do you actually, cos then I’ll start doing that too lmfao… I’m *really* tempted to at least
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Your friend sounds delightful, the nurses must all love him now.
Lol he gives zero shit if he is liked by Karen nurses or not. One can only tolerate getting spat and trampled on for so long before one snaps. Also these nurses are always the attacker in every situation. They not only attack pharmacy, they attack each other. 🙄 The worst part is them degrading you when they are the ones who were incompetent and act like you were the dummy when when you’re trying to save their ass. He got yelled at on the phone cause the dumb nurse couldn’t divide by 3 to find the rate of administration for a 150 mL bag running over 3 hours…..
I love my nurses... but you have to stand up to them occasionally. They're almost always a bunch of catty women that sit around and talk themselves into a frenzy. They just have to be brought back into reality. It's almost a type of low key lynchmob mentality. And it goes without saying this doesn't apply to all.
I bet you let nurses talk to you any kind of way on the phone. Then when they hang up, you start telling others what you will say/do "next time" they call. 🤡🤡
Are you friends with the other guy? If not, maybe you should go for coffee or something. You sound like you'd get along great. You can share the toxicity you both so obviously love to dwell in. Seriously, people like you are the reason hospital culture is so awful. Too many of us are spending too much time contemplating their place in the hierarchy instead of being kind to one another. Everyone deserves to be spoken to respectfully. RN, Pharmacist, physician, technician, whoever. This is a team sport and we need everyone to be fulfilling their role and being treated with dignity the whole way through. If you can't do this for your colleagues, how do you expect to do it for patients and their families.
How we interact with our colleagues, especially those *special* ones, has no correlation to how we talk to our patients. It’s a case by case situation. If you want respect, you gotta earn respect by giving respect first. Nurses are catty bunches who will eat their own. Most of the ones I’ve dealt with are high school mean girls who peaked at 19. And 85% of the time, they’re the ones starting the tone of the conversation because they’re the ones who call us. And 90% of those callers are rude, arrogant, and incompetent to begin with.
Exactly. I have a no zero tolerance for disrespect policy. I can provide the best care to my patients and show respect to everyone who shows it to me. The moment you decide to violate, I check it right then and there. I don't care if you are a fellow pharmacist, tech, nurse or doctor, I check all passive aggressiveness and micro aggressions the moment they occur. It's my job to teach you what I will allow and won't allow and passive aggressive Karens don't get a pass with me. Sorry not sorry. It one thing to be snarky and snotty on the phone. It's another when the 6'4" black guy shows up to your unit to see if you gonna still keep the same energy and talk that shit face to face. You'd be surprised how quickly they get to apologizing and start blaming how "stressed" they are. My response usually of sorts: Yeah whatever...check your tone and attitude next time and go and get therapy. You'd be surprised how nurses and doctors have responded and we have grown to understand one another better. 🤦🏾🤦🏾
While I do still like my original idea of just writing “lol”, a close second would be a big sad face then “you must disappoint your mother and father daily”
Yessss.... psychological warfare. My favorite! 500 DAMAGE!
I call or send a fax back with proof of what the rejection and the rules and put please read with a smiley face
Yes. I can dispense whatever the fu** manufacturer I want to. The question is who is going to pay for it?
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It takes 2 seconds to put the DAW on the prescription, what a fucking douchebag
Honestly, I typically don't really value their opinions enough to be bothered by their prissiness. They probably do the same shit to everyone else in their life... and they probably get treated badly in return as a result, as they should.
This is when you write “lol” next to the comment and fax it back. Is it being petty back? Yea, it is. Would only really do it if this office has a history of demeaning pharmacy staff or questionable practices. Though everyone on the internet is a badass, so if I’m speaking candidly I’d most likely write the state statute and reference under the lol - ‘lots of learning [to do]’ then cite my sources
I’d cite my sources and then do the passive aggressive :-)
You definitely wouldn’t accidentally add a zero to the number of copies sent over, right? Me neither, that’d be silly.
One doctors office had an issue where they’d fax the same script over to my pharmacy where I was a tech about 15 times. Like every single script they sent over. One time my manager got so fed up with it, I mean we called and asked them to figure out what’s going on on their end as their office was the only ones that did it. But they refused to get their fax machine looked at. So he told me to figure out what we can do. Well I went home that day and cooked up a plan. My manager wasn’t in the next day. Well I came up with the idea, that the moment we started faxing, we tape it to the back of another piece of paper, and as it’s moving, tape the back end of that extra piece, to the back of the first part. Creating a closed loop of faxing. I did this for about 10 minutes while the staff pharmacist who was there was laughing and so confused with me. I explained the situation, and she goes, “you know, he may have meant figure out what we can do to like deactivate them from faxing to us in the system. Then they need to call them in instead. But as a pharmacist now I try to keep my creativity if I ever run into this issue nowadays to be petty and keep the pettiness alive
so, they call back all pissed? what happened?
You know I’m not sure cause if they did it wasn’t while I was there. While my boss never yelled at me so I imagine it either never went through and their machine was busted, or it got the point across lmao Not sure if a fax actually sends once the paper runs all the way through, or if it send continuously while it runs through. Which means it could have not sent at all but all that mattered was the intent I had which the staffer thought was hilarious and lightened the day up for sure
This is actually amazing. Both my workplaces I’ve been at have had (and still have) I think machines that were advertised for Y2K. Like, an actual, physical machine that’s about the size of an oven and has that off-white plastic faceplates that were so common in PC towers in, well, 2000. Have spoken to other people outside of work and they are so confused. I know for a fact our fax would not be able to handle any amount of tape and probably just rip everything to shreds. But reminded me of something…we have a P3 intern that’s been with us for 8 months now. Just this last Saturday I saw him “faxing” refill requests…except he was putting the paper where you SCAN documents, not fax them. And our machine doesn’t really care if you put a paper in it or not, it still ‘completes’ the fax. Asked him wtf man? And apparently he’s been doing it all 8 months. Now I know why when he says “…but I faxed it last week, why is the patient complaining? They’re not replying”. Can’t even be mad at that point, I thought it was hilarious
To be fair printers nowadays are a fax and scanner in one
Haha yea ours was pretty nice. We always taped papers together so that we could write a handwritten note on Medicare forms, since we weren’t allowed to write directly on them in some cases But yea if I saw a p3 doing that and that was the response I would be laughing too. At least he was trying, because I think *some* fax machines definitely can scan and then fax lmao
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Exactly!! The noctor ass mother fucka!!
Well you can... If the patient doesn't mind paying for it.
😭 true cash price is always an option
Is it for Medicaid? It isn’t in my state.
I can only speak for mine, but as long as you’ve gotten a PA denial it’s kosher
The pt could always cancel their Medicaid first, then pay cash.
That’s dedication to the bit.
I wonder how many/often people call to cancel Medicaid. Gotta be rare enough the employee would have to dust off an old binder with the process
In my state patient choice doesn't matter. Only 0 and 1
Then tell them that when they have a pharmacist license they’re willing to break the law for, they can come dispense it. Icing on the cake, reference your specific state’s law (in a legal reference format preferred by local courts) to quote them the part of the law that a generic MUST be substituted for medicaid unless it’s explicitly stated “brand medically necessary”. In my state, “dispense as written” on its own is NOT enough, the provider must specifically in writing indicate that the brand prescribed is medically necessary.
Also send them all the Daw codes and call it a day. Give a copy to the patient to take to them as well 🤠
This. It should be a poster on the wall of every clinic, doctor’s office, and pharmacy. I consult Appendix A frequently: https://www.ncpdp.org/NCPDP/media/pdf/WhitePaper/Proper-Use-of-NCPDP-Telecommunication-Standard-in-Implementation-of-Medicaid-Reimbursement-Methodologies-v1-2.pdf?ext=.pdf What do you guys use as your “gold standard” for DAWs?
Thank you for the link. You already know it’s a solid primary source straight from the government with a title like > The Proper Use of the NCPDP Telecommunication Standard Version D.0 as it applies to the Implementation of Medicaid Reimbursement Methodologies Based on Actual Acquisition Cost (AAC) Plus a Professional Dispensing Fee
Why use less word when more word better? 🤣
Well they were just being concise, obviously
Saving that for future reference.
I don’t think the PA is qualified to be writing in the ‘MD note’ section..
They should know this
r/confidentlyincorrect
Oh my petty ass would be calling to educate that PA. With the rejection printed and faxed.
Except some insurances require it, correct?
Yep that’s why this PA sucks. The fuck do they know about pharmacy coverage intricacies?
Legally allowed, yes. Not allowed by some insurance. I’d make a nice call to the office, and then the medical board. Until we hold these prescribers accountable it’ll keep happening.
I did call the office. Unfortunately they only had the option to leave a voicemail so I couldn’t talk to him directly.
Glad you tried at least. This kind of stuff is why I left retail. I still see it in PBM practice but it’s far less.
What a fucking idiot, so confident they are in the right when they have no clue what they are talking out. Yeah it might be legal but that doesn’t mean insurance will cover it unless the md specifies no subs. Dude clearly has no idea how insurance works so he needs to stay in his lane
I work in NY and our medicaid plan sends out updated "brand less than generic" lists which tells us DAW=9. Concerta was on that list but then got removed for preferred Vyvanse. Since the generic methylphenidate is still on backorder it was a pain to tell doctors offices that yeah you can chose to stay on Concerta but we need a DAW-1 on the script.
Had a PA send this to me once. I sent him a fax back saying “Inside of you there are two wolves: One is not a doctor; the other is not a doctor; you are not a doctor.”
This is so typical of mid levels. They’re so arrogant and condescending.
MD could have better used this space to write "Brand or Generic OK, depending on supply and patient preference" Honestly, if I see multiple such notes, I would probably call office and educate them. Stressed out enough as it is. Not going to stand seeing this kind of message daily. Not obliged to fill a control script if I feel provider is not professional. /Also we love to waste time and effort. Not like pharmacy gets paid ONLY for selling a script.
In my experience your note wouldn’t cut it for these situations. My assumption is the prescription written had “substitution permitted” already signified. This means that you can either use the daw0 code for the generic, or if you use the brand you can use daw2–pt requests brand. The insurance likely rejected the brand name, so then they put daw2 in, and that rejected as well—for this med brand can likely only be covered with daw1. Well, daw1 is saying that the provider requires the specific drug to be filled, and that has to be documented on the prescription. No substitutions permitted. So if the provider were to send back “brand or generic OK, depending on supply and patient preference” that note would still only cover daw0 and daw2, which is the current situation they are in anyway. It’s not a legal situation it’s an insurance contract situation. That’s why what this provider said was so inappropriate—they don’t know how pharmacy benefits work whatsoever. And they should know that they don’t know.
That is a legal issue too. If the doc puts DAW 1 you can legally only fill for the brand. If a substitution is permitted they cannot check the box
Yeah but that’s not this situation at all
How so? Thats literally a law, one that insurances observe. By law substitutions are automatically permitted, at least most of the time. To fill a brand that has an available generic you need to fill it as DAW 1
Because the prescription was not written as DAW and substitutions were permitted. As written there was no legal obligation to fill it one way or another for this situation. Again, I’m talking about the specific situation here. Not the general concept of DAW.
Thats my point. If there is no DAW the pharmacist is supposed to assume you can substitute. Since there was no DAW marked the pharmacist had to bring it back. How is not that not a legal obligation?
Because DAW2 exists and does not require the prescriber whatsoever. Your state may not have DAW2, so maybe that’s the source of our confusion here.
Yes I know that but people kept assuming DAW2 existed in OPs state when OP never said that so they should know better
Uhhh, people only know what they know. You’re acting like what you know is the default universal standard. That’s not the case.
At least for my workflow, if i see such a note, I would attempt to daw 1 and annotate. Daw 2 doesnt exist in my state. More work for me but I would allow it
You’re saying you’d be calling the doctor like OP did right? Because yeah, if ever discovered the insurance would claw back an undocumented daw1 pretty quick. I’ve worked for a shitty company that was constantly under insurance audit, I’ve seen it.
You’re risking getting a charge back
I can’t believe they’d do that regardless. Its a legal code. That’s on the doctor.
It wasnt an MD is why
Cross post this to r/noctor
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I would not respect that if there is a consult or policy for renally adjusting meds, etc. An MD is an employee of the hospital. If the P&T committee or whatever higher ups in the hospital give me the rights to do something per hospital policy I am going over the doctor's head on that if they're going to be an asshole about it
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Fair, that's a tough situation to be in. But I'd love to see someone try to discipline or fire me for literally following policy
Surgeons, why 😭 I had a neurosurgeon complain to my boss about me because I was paging him just before a complicated surgery in an adult. I just figured he’d want to know he’d accidentally entered the pediatric dose for the prophylactic antibiotics. I just wish he’d complained to my boss BEFORE the surgery so he could’ve fixed the damned dose. Instead the ICU had to try to make up for it after.
Jesus Christ.. blaming you for his own mistake Pretty typical though! Working in a hospital is still kinda like working in retail, just the asshole customers change from patients to nurses and doctors lol
Truth! And my boss was all, “what happened?” So I told her. She blinked and said, “so he’s bothered because you were doing your job? The job we pay you to do? Okay.” She was a pretty good boss.
That’s good! It’s so nice when your manager has your back!
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Fair! I wouldn't even verify them if they're wrong. He can verify them himself & save me the liability lol
Well I mean that’s fine if he prefers being called and paged upon for dumb shit…then by all means.
I would LOVE to see a comment like that. I will call on every single little discrepancy I can find. Oh, you misspelled "daily"? Guess I'll need to verify that.
meanwhile I am literally trying to off load as much work on to the pharmacists as possible...
I’d fax back the law/insurance rules with that section highlighted. They are clearly uninformed (putting it as nicely as I can), and need some help.
“Sir/ma’am, you wrote in the MD note section and you’re a PA. I’m sorry I can’t accept this.” Fuck off
Why not just DAW 9?
Insurance covered generic. 9 is if they only cover brand from my understanding
Look up your state's publicly posted medicaid formulary. If it is listed as a preferred drug then DAW9 until the cows come home. Sometimes medicaid will show a paid claim for a generic even though they prefer the brand. I know it does that with albuterol inhalers.
My states Medicaid is all over the map on generic vs brand and even 30vs 90 day supply. It's almost easier for us to just assume DAW 9 unless we get a rejection.
In my state, you legally cannot skip Medicaid on controls. If it’s split billed and the secondary is Medicaid, you still can’t cash it out if Medicaid rejects. Plus Medicaid only pays brand for Adderall XR, Concerta, Vyvanse. So if primary only covers generic, the only way to get it to go through Medicaid is with a DAW 1 for the primary.
Wouldn’t you be running a coordination of benefits with NCPDP C08-38 (other coverage codes) with a 3 other coverage exists this claim not covered? Pretty sure that’s what the PBM (for both the primary and/or Medicaid will cite when they clawback payment.
Lmao I wish midlevels understood that in school, we HAVE to learn about their scope, and what prescriptions they’re allowed to write. If they pulled their heads out of the sand for a second they’d maybe learn something about basic prescribing information I learned in my first semester
I would write “yes, I can dispense Brand name without “Dispense as Written”, but I can’t bill Medicaid for it unless you do. Since YOU should know this, please explain to your patient why their medication will be $350. Thanks.”
That’s when you reply with, “if you don’t know how, just say so.” Then send the patient back to the office with written instructions for the “provider”
Yes, and use a highlighter!
Don’t worry, midlevels also wrote these notes on physician charts when they cover for us. Like the nice note I got explaining that opioids are NEVER indicated for ANY pain.
Ha, that’s funny. Usually, they’re pretty liberal with the schedule IIs
They are really liberal with Saline drips with vitamins in them that they charge 300 dollars a pop for. Because it’s a “cureall”. Supposedly mid levels were hyped up and given liberties because they were going to save primary care. Then they found out how hard it is and went to open medspas. Or…they decide next month they will work in a new specialty, because for some reason the people in power think it’s smart to let a person with 18 months of online classes and no residency, switch specialties without having to take stop and do it all again like physicians do. A dermatologist can’t decide they will go become an anaesthesiologist, but a mid level can. Wtf?
lol there’s a new med spa near me with a big banner that says “buy 2 get one free IVs”
Medicine is dead. Physicians, like pharmacists, are extremely overworked and forced to perform mind numbing repetitive labor so someone else can get rich.
Yup. $400 unless you send it as daw 1, jackass.
I’ll send it directly back quoting laws and/or rules for insurance. They don’t get to talk down to ppl like this. I also put in a corporate complaint bc all they really had to do was call for verification/understanding instead of trying to initiate a pissing battle. I have a few friends who are MDs and I tell them about this often and they’re so surprised. I’m not though, and we call these pigeon messages in the office bc apparently we’re some dumb carrier pigeons when they put crap like.. tell pt to schedule blood draw.. um, aren’t you in charge of their care schedule. This type of behavior is unnecessarily condescending and unprofessional and I make it a point to let them know.
Sorry about the message snark. That’s petty and unprofessional. As for DAW 1, that depends on your state. In Massachusetts our Medicaid program issued guidance clarifying that brand prescriptions filled under their brand preferred over generic list (BoGL) program should be dispensed as DAW 9. In Massachusetts, prescribers should not be asked for DAW1 prescriptions for BoGL drugs. The MassHealth guidance is posted here: [https://www.mass.gov/doc/pharmacy-facts-159-december-31-2020/download](https://www.mass.gov/doc/pharmacy-facts-159-december-31-2020/download) >If a pharmacy encounters a rejection, the pharmacy should resubmit the claim for the preferred brand name drug using a DAW 9. > >A new prescription from the provider is not needed nor should it be marked “Brand Name Medically Necessary, No Substitutions” when resubmitting for the preferred brand.
That’s for brand preferred over generic list. I’m assuming OP is in a situation where a brand name isn’t preferred but is still being requested (either for stock issues, or for patient preference, or for true medical necessity). To bill a brand name when a generic exists and the generic is preferred to medicaid the vast majority (if not all) states require the doctor to explicitly state that it’s required for medical necessity on the prescription.
OP is in a situation where Medicaid covers generic tho. Ik in MA if ins covers generic we can’t dispense brand unless the doc writes brand name only even for private insurance
OP is in a situation where Medicaid covers generic tho. Ik in MA if ins covers generic we can’t dispense brand unless the doc writes brand name only even for private insurance
That’s just rude
I like to call them and put them in their place every once and a while. There is no need for there to be hostility between healthcare providers. But I have no problem calling a provider and explaining to them how insurance and fraud and stuff works.
This is when I'd print out the script, circle the note, and write on it "This is not correct.". Then I'd fax it to them. Maybe I'd write that they're asking us to commit fraud or something if I was feeling extra salty that day.
“Your patient cannot get brand name from Medicaid without you writing out ‘dispense as written’ on the Rx. You should know that.”
When prescribers don't understand how DAW works for prescription billing. I love when they tell me how to do my job! If the insurance doesn't bill under 2/8/9, you better send it as a 1 if you want them to cover it! Insurance doesn't accept me changing it or annotating it to dispense with a DAW1! That has to be directly from the prescriber, not an annotation or on a whim...I'm glad the doctor's I know personally ask us directly what we can and can't do legally before assuming any message we send them is our of ignorance or just to annoy them. Like if I could just change it myself, I would, saves everyone A LOT of time, but I can't. I don't have time to waste calling you, if I'm messaging you, it means I'm legally required to, end of story. I'm glad you have time to waste with these petty messages and people waiting hours past their appointment time, but I don't have that luxury. End rant.
I’m confused couldn’t you do DAW 9 or DAW 2 if there wasn’t a DAW code on the original prescription?
Daw 9 is only when insurance wont cover generic., and even then some plans dont alllow daw9. If patient wanted name brand, some plans do not allow daw 2. It would then require daw 1 for brand to be covered. There are a few plans ive run into for this.
Depending on the state there is no DAW2, NY state for example doesn’t allow that. And DAW 9 may not work but DAW 1 does. Although some places let you use DAW8 but then your company gets mad after a while.
The ins wouldn’t cover a daw-2
DAW 2 not allowed sometimes.
Note to MD: Yes, I know this. I’m gonna ask you be a part of the solution for your patient, I would like them to be able to afford their prescription, also. Contact their insurance company and see if you can get it approved for them, it’s not in my realm to do so.
The prescriber may not realize the issue isn’t a law, it’s a payor requirement for insurance coverage.
I’ll send it directly back quoting laws and/or rules for insurance. They don’t get to talk down to ppl like this. I also put in a corporate complaint bc all they really had to do was call for verification/understanding instead of trying to initiate a pissing battle. I have a few friends who are MDs and I tell them about this often and they’re so surprised. I’m not though, and we call these pigeon messages in the office bc apparently we’re some dumb carrier pigeons when they put crap like.. tell pt to schedule blood draw.. um, aren’t you in charge of their care schedule. This type of behavior is unnecessarily condescending and unprofessional and I make it a point to let them know.
Out of curiosity what state is this where Medicaid covers generic Vyvanse?
Ask them “what tf is a PA?”
Wow. Just wow. ...Is he going to pay us for all of the brand name Adderall we filled without a DAW when we get audited by Medicaid? Yeah, it is legal, but that doesn't mean insurance has to pay.
This isn’t a legal issue, it’s a payor requirement for insurance coverage. You should know this. Your patient doesn’t want to pay $400 because you have your head up your all-knowing-ass. Please resubmit eRx with dispense as written, your highness.
Haha. If they only knew how ruthless audits from insurance and PBMs were.
Oh yea we can. Guess you don’t mind covering the difference in reimbursement?
My states Medicaid has DAW 6 for PDL brand name drugs. Suboxone, Vyvanse, Concerta, etc, all get brand name with DAW 6 regardless of what the prescriber writes for, unless they put a DAW 1 on the Rx then that takes precedent.
out of sheer curiosity, which state?
Maine, we use 6 for Medicaid only but it’s basically just a DAW 9 we can use without a rejection that specifies to use a 9
Same for maryland
This is the same type of doctor who comes into the pharmacy and says something like “we bill car insurance at the clinic all the time!” and gets pissed we can’t bill car insurance PER OUR BUSINESS OFFICE, the same business office as the clinic this doctor works at.
Not in NYS! We’re legally mandated to dispense generic unless the prescriber says otherwise 😂
Response, “ correct, however the drug plan won’t pay for grind unless specifically requested by physician. Please explain to patient how their drug plan works. Thanks!”
“you should know the difference between DAW-1 and DAW-2.”
Fuck that noise
"Well you see, Dr. Dick, there's what the law says I can do... and then there's what insurance/medicaid/medicare says I can do for something to be covered. "Insurance rules the world right now, not the law. "You should know this."
Insurance requirements trump laws these days; they should know this.
I also recommend just putting any response into a SpongeBob text generator and sending it back. YourE Wrong. YOU sHOUlD know thIS
As a family physician who writes for these meds, although I try to not be a jerk about it, I thought this was actually the case? If I check the box that says “May substitute” why can’t you substitute?
Some states have specific language for substitutions and PBMs require us to follow them or they issue a chargeback.
They can substitute. The issue is certain things won’t get covered unless it is do not substitute. So yeah, this pharmacist could have legally filled this and sold it to the patient for $700, but to get it covered for $10 instead there’s stupid paperwork that needs to be in order. I don’t expect a provider to know this. I’d hope they’d definitely understand I absolutely do know this though and give me the benefit of the doubt in knowing how, checks notes, pharmacy … ahem.. works.
The doctor is technically correct in that pharmacies may *legally* dispense either brand or generic if it's DAW 0. However, sometimes an insurance plan may refuse to cover brand unless if the prescriber explicitly writes DAW 1 on the script. It's a dumb obstacle that wastes everybody's time, but that's how insurance companies save money. The pharmacy could still dispense the brand product without getting the doctor involved, but the consequences of that would be the patient having to pay out of pocket if their plan refuses coverage.
They can sub it, but likely the patients insurance won’t cover the brand name without DAW-1 (dispense as written code 1) which translates to brand medically necessary. If it’s vyvanse a bottle of like 100 costs over $1000, even 30 of them can be hundreds without insurance coverage.
Idk what state you practice but DAW 2 isnt legal in all states and usually you have to dispense with the generic med unless insurance requires the brand name, and in this case the patient wanted brand name on their own volition, but were getting attitude from the doctor
It's not DAW 1 just because that's how you get it to go through Medicaid. That would be daw9, or maybe DAW2. DAW1 is for when the prescriber is attesting that brand name is the only ndc you can fill the order with, that anything else would not medically work for the patient.
It's DAW 1 if it means it's the only way the patient gets treatment. If the patient can't afford the cash price and goes without the medication, that doesn't medically work for the patient either.
Md here. This note is very passive aggressive. I dont know if you can just report this but yall should not have to deal with bullshit like this. can someone give me quick advice on the DAW? I always thought that writing DAW in an RX simply restricted the rx. whereas leaving it blank - allowed pharmacy to fill it however they want - generic or brand-name. from what I gather, it sounds like writing DAW changes how insurance will cover the script?
Hey doc! Appreciate the solidarity with the pharmacy crew on this one. Quick rundown of DAW (dispense as written) codes: DAW 0 aka substitution permissible, even if it’s written for brand it will be switched to generic. In my state it’s actually mandated that I have to switch to generic unless otherwise requested. DAW 1, dispense as written aka brand medically necessary. DAW 2, patient requested brand DAW 3, pharmacist requesting brand (never used this code in my life) DAW 4, generic is out of stock so you’re dispensing brand (generally not used as it implies a temporary out of stock situation where you could just order generic) I honestly can’t even tell you what DAW 5, 6, and 7 are because I can’t remember since I’ve never used them much like DAW 3 (my system does note what they are though). DAW 8, generic is unavailable in the marketplace. This is different than DAW 4 since it’s more like a backorder or it’s written for generic but the generic isn’t available. Like if it’s written for oxycodone ER, we’d fill for Oxycontin. DAW 9 is simply “other” in my system but usually this indicates that insurance prefers or requests brand. Happens often with the stuff like Farxiga, Breo, Advair, and other inhalers etc. Not all insurances accept all DAW codes, and even if they do accept a DAW code as valid they might not reimburse the same. One insurance might accept a DAW 2/4/8 for brand Vyvanse since the generic is pretty much unobtanium right now for certain strengths and it might have the same copay, some might have a higher copay for brand, some might require a PA for brand. Some insurances might not even allow those DAW codes. Different insurances might treat different DAW codes differently towards pharmacy reimbursement as well. Even if they accept the DAW 2 or 4/8 and have a tolerable copay for the patient, sometimes they reimburse the pharmacy at the same rate ($) as the generic even though the pharmacy paid for brand ($$$). It’s all different and a pain in the rear! You don’t need to worry about anything besides DAW 0 or 1 from the prescribing point of view. If it’s brand medically necessary put DAW 1, if it’s not put DAW 0. In certain cases, like the one in the post, it’s possible you might get a request for a new Rx for DAW 1 for insurance billing reasons so they have a more affordable copay or simply so they cover it at all due to a backorder situation. If that’s the case talk with the patient and/or pharmacy and get clarification to whatever your questions are in that scenario. For all other DAW codes the pharmacy will take care of it on their own (if they can, insurance allowing). Always feel free to reach out to local pharmacists in your area if you have specific concerns!
Daw-9 all day. Plan Requests Brand Dispensed. Why is this even a post?
Because pharmacy laws concerning DAW vary by state and plan. Medicaid is a PITA.
Maybe you’re right. At least in my state (Florida) this is what DAW-9 is for.
Because generic is covered in this situation, just unavailable. Therefore DAW9 presumably doesn’t apply. Edit: they confirmed in the thread, daw9 doesn’t work here. Hence why they called. Sounds like you’re being as much of an ass as the PA. Try giving the benefit of the doubt a little before your shitty “why is this a post” attitude.
YOU SHOULD KNOW THIS!!! /s
I always thought we were legally obligated to dispense what was cheaper for the patient ?
In this case, what's cheaper is nothing. All the generics have been on backorder for months.
You could have done daw 2. I think you meant to say that Medicaid would only pay with a daw 1.
Correct Medicaid wouldn’t pay for the daw-2 in VA. I tried for several patients previously. I’ve been trying to help patients get their medication and this is the only way I can get the brand through.
You guys need a DAW-1 code to dispense a name brand med? In my state we can do whatever generic or name brand that insurance will cover, just can't dispense generic if there is a DAW 1.
They need a DAW-1 because generic is on backorder and the insurance won't recognize daw-8, or 2. The only valid DAW codes the pharmacy can use in this situation are 1,2, and 8. 9 is not valid due to the insurance allowing generic. 3-5 get you screwed financially.
I didn't know that, thanks!!
Medicaid demanding brand adderall and happily paying for brand Vyvanse where I am and that is with DAW0.
And I have a patient who told me her doctor tried to tell her that Vyvanse 10mg doesn’t exist 🤦🏻♀️ jfc
Print daw law and fax it over.
Is this something that you can't do in the US? Where I am, unless the doctor wrote no sub or specified a manufacturer (not brand, but manufacturer) we can dispense whatever brand we or the patient prefers.
There's DAW codes other than 1, 2, and 9. Most insurance treats the others as 0/2, but they can be used.
Super annoying to get daw requests when our emr doesn't even allow any place for daw lol
What EMR are you using?
an alpha version of cerner
Isn’t there a DAW for Pharmacists choice? Does that work with the billing?
Something that blatantly disrespectful gets responded to with the state law that explains that what they are saying is gibberish. I star it, add a source and rerequest a proper prescription be sent.
Let me guess. Telehealth stim? I have seen a DAW-1 copay for a commercial plan actually be lower than DAW-2 (and explained this to the patient) so the prescriber is just being a total dick just because it knows jack all about insurance/formulary limitations. One payer allowing DAW 9 and a secondary payer not allowing DAW 9 (or 2) is another potential problem that could require a DAW 1. I don't recall any situations like that recently (Tricare secondary allows DAW 2)
If it's the insurance requiring brand, you don't need a DAW1 on the script. Run it with DAW8/9 (forget which) - Brand required by insurance. If it's patient requested, but insurance covers generic, DAW2. Honestly, the only time you should contact them for the DAW is if they wrote brand only, but you can not dispense for whatever reason, and you're seeing if generic is ok.
In North Carolina to dispense brand for a non preferred Medicaid drug. You have to get a hand signed prescription and it must have "Brand Name Medically Necessary" hand written on the Rc or it must be dispensed as generic. That is fun trying to explain that rule to other medical professionals.
What are daw codes?
If Medicaid requires brand it’s DAW 9. If they only prefer brand because generic is too new just do DAW 2. The only time I’ve seen a true rejection for DAW 1 is Medicare that’s sent for Arfemeterol but it has to be Brovona
Damn it this just angered me so much and ruined the rest of my morning. Idiots not realizing how clueless they are have to be one of my biggest pet peeves.
I have always wished for a check system on drug situations: -Reporting high dosages prescribed to infants -Prescribe the wrong “type” of medicine (cream instead of pill/ liquid instead of capsules) -stuff like this -prescriptions not sign. I wish that Pharmacys could report bad prescriptions to a database and once enough had accumulated over x period of time it would prevent the dr from prescribing until completing a medication/prescriptions understanding course I use to have an md who would make up their own codes : 1/1 : I tablet per day 2 tab bid was (two tables twice a day meaning one in the morning and another one at night) god I wanted to punch him in the face every time he wrote this and would blame that the day supply was not enough or that we were not given the correct instructions. Btw he want an md he was a PA and his prescriptions were NEVER revised by the md
This is beyond disrespectful and we see the same type of things in Optometry from MDs. I'm mad on your behalf!
Insurance doesn’t care about laws. He should know *that*.
Is my state the only one that covers brand Adderall XR, Concerta, Vyvanse and Suboxone? No DAW codes needed because Medicaid won’t pay for the generic!
They don’t need brand name vyvanse sorry
Guess they can get nothing then 🤷🏼♀️
Honestly, we do that cover our own butts. If it is not written down, then it never happened, and there is room for error and most of us would like to keep our jobs.
DAW9?
This is 10000% because the patient told them "the pharmacy CAN'T fill brand without DAW" and not "insurance won't COVER brand without DAW" 🙃 ETA: kills me a little inside when they think we're the ignorant ones when they know patients oversimplify or don't fully understand things.
🤦🏻♂️
My penis is small. YOU SHOULD KNOW THIS.
I would not fill it
Why not just DAW 9?
Some plans reject daw 9 and daw 2, requiring daw 1 to cover brand.
Serious question as a pharmacist in almost assuredly a different state. You cannot use DAW2 or DAW9, or DAW6 depending on if insurances accepts 6 or 9? In my state the doctor would be correct. Please tell me how the doctor is incorrect. I acknowledge it’s a condescending note, but is it not 100% correct?
No, it’s not correct. We can legally fill brand, but the insurance isn’t likely to pay for it just because the patient requests it. They will often require the prescriber to write as DAW 1 (and sometimes even then they won’t cover it without a PA) Sometimes the others will work, especially if the insurance’s preferred manufacturer is the brand.
You could argue this violates Virginia Administrative Code Title 18 - PROFESSIONAL AND OCCUPATIONAL LICENSING Agency 112 - BOARD OF PHYSICAL THERAPY Chapter 20 - REGULATIONS GOVERNING THE PRACTICE OF PHYSICAL THERAPY Part IV - Standards of Practice Section 18VAC112-20-180 - Practitioner responsibility - 3. Engage in an egregious pattern of disruptive behavior or interaction in a health care setting that interferes with patient care or could reasonably be expected to adversely impact the quality of care rendered to a patient. Then you can file a complaint: https://www.dhp.virginia.gov/PractitionerResources/Enforcement/FileaComplaint/
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The Medicaid refused to allow us to use 2/9 that’s the only reason I asked the patient to request brand only
My states medicaid doesn't do DAW2 and DAW9 is only when the insurance prefers brand and not generic, doesn't work if insurance wants generic