This is a request I am getting electronically more and more often from pharmacies. I usually turn it down. Let me explain why.
For medications the patient is already on, I pretty much always refill them for a whole year in 90 day increments. Some people get their medications bubble packed in 4 week increments, and then I do the refill for 28 days with 12 refills.
But the reason I turn down the electronic requests I get from pharmacies to change my 30 day script to 90 days is that I have issued a new prescription that requires some kind of monitoring.
New starts of furosemide will require a potassium level and possibly a creatinine before the first 30 days are up. The same is true for spironolactone, in this case because it can raise potassium levels and carries a greater risk for causing kidney damage. The same is true for lisinopril, an ACE inhibitor, as well as the newer angiotensin receptor blockers. I had my own near miss with lisinopril more than 10 years ago, chronicled here.
A new start of a modern antidepressant, like the SSRIs, requires a clinical followup within a few weeks to make sure the patient isn’t getting suicidal or hypomanic. Even a 30 day script without followup is pushing your luck. 90 days in a non compliant patient missing their followup is medicolegally indefensible.
The other day I increased a PTSD patient’s prazosin for nightmares from 1 to 2 mg and sent in a 30 day script for the new dose. She still had some 1 mg capsules left. I neglected putting “FILL WHEN CALLS” on the “Sig” of the script. Boom, instantly the pharmacy shot off a “Patient requests 90 day script” refill request. You can’t split a capsule in two if, after a little while, you decide the higher dose doesn’t agree with you. In this case I authorized the 90 day script ONLY if they didn’t fill it until the patient had used up all her 1 mg capsules at two per day and knew that this dose agreed with her.
My bottom line is:
I am the doctor. I know what I’m doing. I work hard to save my patients money, and look up costs and copays every time I prescribe a new medication. Just like I carefully choose the medication and the dose, I deliberately choose which amount is appropriate for the situation.
A Country Doctor Writes: 
You are so right!
For those with poor/overdue followup and we have limited their fill to 30 days and then 14 days, I’ve been hearing insurance will not pay for the Rx if not sent in for 90 days. Anyone else encountering this?
I am the doctor. I know what I’m doing. I work hard to save my patients money, and look up costs and copays every time I prescribe a new medication.
This is so disappointing. Doctors should be saving lives, and not be beheld to the insurance companies. I am a doctor and this robs time every day from my delivering health care.
Disgusting.
Thank you for bringing this to people’s attention! Sadly, it’s often an automatic feature at the pharmacy that the pharmacist or technician doesn’t even see what medication is being requested of doctors to change to 90 days. I was frustrated when I received this request one time because I knew the patient certainly did not request 90 day supply, as I had just talked to her in the clinic on why I was only starting with 30 days of a new prescription. When I called pharmacy, I felt my explanation on my rationale went to waste because I was talking to someone who had nothing to do with the company policy that set this into motion, nor was she able to tell me where to file a complaint to stop this lie about patients and a waste of physician’s time. She helped me turn off the setting on that patient’s account, so this would not happen again for that one patient, but there has got to be a better way than calling to each patient’s pharmacy to turn this off (or even asking patients to do so).
A bane of my existence. One of many!
I think 90 days supply is a great idea, provided patients follow up with physicians every 90 days for check ups. If not, then they will not get the supply though.
90 days for a new prescription is sometimes too much! (As I described.)
Could not have been said better.
As a patient on chronic medications, I would prefer a 90 day supply if it is less in price. My physicians know me well over the years and now retired know prescriptions are a major expense especially those in the “donut hole” like me. I am fortunate to have a pharmacy technician with Walgreens assigned to me who follows my medications and also looks at drug cost.
Agreed. My issue is a new start medicine. Also, in some cases medications that are particularly lethal in overdoses, like amitriptyline.
There are four legs to this stool:
1. The patient
2. The physician
3. The pharmacy
4. The drug manufacturer/distributor
When the physician prescribes without a visit:
1. The patient benefits
2. The pharmacy benefits
3. The drug manufacturer/distributor benefits
4. The physician is left holding the bag and the responsibilities of monitoring the patient. That’s one of the reasons why I must see, reevaluate the patient, etc. at least 3-4 times per year when she/he takes maintenance drugs; even when the patient is in a capitated insurance coverage.
Thank you for the validation. This is how I practice. Patients change, they see other doctors that prescribe medicine that interact or overlap. Thank you for sharing clarity.
I ignore all requests from pharmacies unless it is a prior authorization request. I advise patients the requests are sent automatically by machines that use no discretion and the patient can contact the office if they have questions or need a refill. And if they do need a refill, they likely are due/overdue to be seen so calling the office provides a great opportunity to help the patient schedule their appointment. I used to get refill requests because the pharmacy put the prescription on “Hold” and never bothered looking to see they already had a new prescription before requesting another. Thus, I simply ignore them now.
Thank you! And beautifully said.
Totally agree
Increasingly, I am finding that the pharmacy sends out this request but it is really them requesting the 90 day supply. I work with dialysis patients and see them at least three times a month, and more often than not when I asked the patient if they want the 90 day supply, they tell me they either don’t care (but didn’t request it), or don’t want it (for a variety of reasons). When a patient request a refill on medication, I almost always ask them whether they want a 30 or 90 day supply, so it really irks me that the pharmacy sends a request that is for all intents and purposes a lie. I would much rather have them say that it has the potential to save patients money or be more convenient for them
Walgreens’ is the Evil Empire. I have tried for a long time to fix this 90 day supply insistence. I have been met with blank stares and ignorance on the Pharmacy side. Even when the sig says ” 1 tab a day for ten days”, I will get the “90 day” statement over and over.
Agree totally. I have spoken to multiple pharmacists in the large chains and they all tell me it is an automated response initiated by corporate. I have called corporate and initiated complaints which have gotten nowhere. I have called my NYS licensing departments and once again no luck. Maybe a class action lawsuit would be the answer. Please forward to every lawyer you know!
Maybe NPR can help us…
I agree 100% with the article. When I used to do outpatient pulmonary (I now only do inpatient critical care) I would only prescribe a 30 day supply of a new immunosuppressant with no refills, because the patient was supposed to come in for a CBC and CMP at 4 weeks. One time a patient did not come back for follow up after I started her on methotrexate. 9 months later she ended up in my ICU with severe pancytopenia, septic shock, markedly elevated transaminase levels, and multiple mouth ulcerations. It turned out that her internist had given her refills without checking labs! Fortunately she survived the experience, and the internist learned from the experience when I politely notified him about what had happened.
I’ve stopped taking refill requests from pharmacies altogether. If a patient calls I will consider it but I can’t keep up with digital nonsensical requests.
Been doing same for the last 44 years of my practice So do the other primary doctors in my city FP’s and IM and Peds when appropriate.
I am a rural physician in privae practice in Family Medicine close to 40 years. I raised the same question in medical managemen with cold shoulder response. I am so pleased every one agrees the clinical cost saving with possible risk to consumer. Atleast for the first prescription I advocate governing auhorites consider 30 days or less according to recommonded titration period for a drug under consideration.
Dr Mohan
In Family Medicine we used to prescribe birth control pills for women once a year with adequate refills for the year. What we discovered is women who were due for their “annual” pap and birth control refill often were delayed in obtaining a timely appt. So they ran out of birth control and some became pregnant! Or angry or both! Need to think seriously about the consequences for patients.