You’ve seen your health care provider, and they’ve written a prescription for you, and maybe even said “I’ve sent it to Totally Affirming Pharmacy, they’re usually quick.” So what happens next? Even for people who have navigated health care for years, the path from your appointment to getting your prescription can be rocky and mysterious.
In an efficient (preview it isn’t always efficient) health system, it should be fairly easy to get a prescription filled:
- The provider writes the prescription.
- The prescription goes to the pharmacy.
- The pharmacist reviews the prescription.
- The pharmacist asks clarifying questions, if needed.
- The pharmacist fills the prescription.*
- The patient picks up the prescription (or it is mailed to the patient.)
*It is a very important part of the pharmacist’s job to review medications for safety and potentially harmful interactions (and to prevent fraudulent prescriptions.) Pharmacists may refuse to fill a prescription if it is their clinical assessment that the medication is not clinically appropriate or may cause harm. Some states allow pharmacists to refuse to fill a prescription due to a personal moral objection. We think those laws are buls**t.
What Does It Mean to Write A Prescription?
In the olden days before electronic prescribing, doctors had prescription pad – a pad of paper with their NPI (National Provider Identifier) number printed on it. When they “wrote a prescription,” they physically wrote the details of the medication to be dispensed by the pharmacy on sheet of one of these prescription pads, signed the prescription, tore that sheet off of the pad, and gave it to the patient. The patient took the piece of paper to the pharmacy and gave it to the pharmacist, who then dispensed the medication, if all went well. It could be a HUGE problem for a provider to lose their prescription pad, as a forged signature could be used to get prescriptions filled (ugh.).
Note: prescription pads are still a thing!
Most prescriptions are written in software and sent electronically to the pharmacy now, but physical prescriptions still exist. Today’s prescription pads have multiple security factors built in to make it harder to forge a prescription even with the physical paper.
Physical prescriptions are most often used to prescribe Schedule II drugs, but can also be handy for travelling. Here’s the DEA definition of Schedule II:
Info Nugget: a provider needs to have a DEA license to be able to prescribe controlled substances. There are five categories of controlled substances: Schedules I through V. Schedule I drugs are the most highly restricted (research use only,) and Schedule V drugs are the least restricted, although still managed.
We don’t usually prescribe Schedule II drugs at QueerDoc. We do prescribe testosterone, which is a Schedule III drug. You may have read our posts about proposed telehealth restrictions on Schedule III drugs. We believe that allowing telemedicine prescriptions of testosterone is necessary and life-saving.
Info Nugget: Refills are prohibited for Schedule II drugs. Schedule III drugs require a new prescription after five refills or six months after the original prescription date.
Who Can Prescribe?
Generally, doctors (MDs and DOs,) physician assistants (PAs,) and nurse practitioners (NPs,) can prescribe medications. Who can prescribe which medications is regulated at the state level. Some states allow PAs and NPs to prescribe Schedule II drugs, and some don’t.
State-level restrictions on prescriptions specifically for gender dysphoria to written by a doctor have been passed by Florida. That is being challenged in court and is clearly discriminatory, as most medications used in gender affirming care aren’t even scheduled, and Florida allows PAs and NPs to prescribe Schedule II meds, which are more tightly controlled than Schedule III – testosterone.
Anyway….
Doctors have the broadest ability to write prescriptions. PAs and NPs may be under the supervision of a doctor for prescription-writing, may have full prescribing ability, or may not be able to prescribe specific medications. State level information on prescribing rights for PAs can be found here.
What Information Needs To Be On A Prescription For It To Be Valid?
To be dispensed a prescription must contain the following information:
- Who is the prescriber?
- Who is the patient?
- What is the medication?
- How much medication is to be dispensed?
- How is the patient to take or use the medication?
- How many refills are avaialble?
- The prescriber’s signature and prescribing credentials (their NPI and DEA license, if applicable)
Your prescriber can also include whether or not you are to be given a brand name or a generic, or a specific brand name, for peeps with allergies and sensitivities and need gluten-free, lactose-free, or other-free versions of a medication.
Why Is There A Delay In My Prescriptions?
The most common delays we see to prescriptions are when pharmacists have questions about
- What is the medication (often, what form of medication is desired)?
- How much medication is to be dispensed?
- How is the patient to take or use the medication?
Both your prescriber’s office and your pharmacist’s office spend a lot of time faxing and phoning back and forth to make sure the details about how and how much are clear and make sense clinically. A lot of gender affirming care is off-label: pharmacists, especially ones not familiar with gender affirming care, may have a lot of questions.
Info Nugget: Pharmacists ask about rectal use of progesterone ALL THE TIME. They expect oral use, so they double-check that yes, the prescriber did really say that the patient can take this rectally.
Pharmacists also run your prescription through your insurance coverage so they know how much to charge you. SO MUCH time can be spent discussing the details of what insurance will cover, and would it be okay to alter the prescription so that insurance is more likely to cover it.
A prescription may get delayed while your provider, your pharmacist, and your insurance (if you have insurance or are using it) go back and forth about what forms of a medication will be covered under which diagnosis code. This can, unfortunately, take a while. Your insurance may require that a Prior Authorization (PA) is obtained before they’ll agree to cover your meds. Once a PA is submitted by your healthcare provider the insurance company may still refuse to cover the medication. If your insurance denies the PA or won’t cover your medication, we encourage our patients to use GoodRX.com to find the most cost effective option. The pharmacist can transfer your prescription to a different pharmacy if it is more affordable (GoodRx let’s you price compare), and you can use the coupons on GoodRx to save money. You will sometimes have to say specifically, “I don’t want to use insurance for this prescription, I want to use this coupon instead.”
Info Nugget: Are you getting an injectable? Sub-Q use of testosterone and estradiol (which we recommend,) are off-label. Your provider may have to convince your insurance company and your pharmacist that yes, they really do intend to order injection supplies meant for sub-q use, not intra-muscular use and that you really do need the number, volume, and gauges of needles and syringes requested. They may also have questions about single-use and multi-use vials and how long a vial may be used.
Congratulations, Your Prescription Has Been Filled! How Do You Pick It Up?
You’ve gotten the alert that your prescription is ready! What next?
Go to the pharmacy!
Info Nugget: Life gets busy, and sometimes getting to the pharmacy just ain’t gonna happen today. Don’t wait too long: the pharmacist will restock your medication after a certain amount of time, and if you haven’t picked it up, will need to go through the filling process again.
If you’re using insurance, take your insurance card with you. Your pharmacy may want to double-check your information. Not using insurance? Check out GoodRX.com for potential coupons.
Info Nugget: If it is financially feasible, you can always choose not to use insurance for medications. If you are using insurance, the name used for your prescription must match what is on your insurance card.
Go to the pharmacy pick-up counter. They’ll ask you for identifying information so that they can find you in their database. Often, a pharmacy will start with your birthdate and then ask for your name. Give them the name that your doctor used when sending your prescription (if you’re using insurance, it will need to match the name on your insurance card.)
Getting testosterone? You may need to show identification to pick it up.
They’ll confirm the medication that you’re picking up, then go find it on their shelves and bring it back over to the pick-up window.
At this point you may need to answer some questions and sign a waiver/disclosure:
- Is this the first time you are using this medication?
- Do you have any allergies?
- Do you have any questions for the pharmacist?
- Do you understand why you are taking this medication and what to expect?
- You don’t have to tell them why you’re taking it, just that you understand why!
- Do you know how to take this medication?
- You can say that your doctor already discussed it with you.
If you do have questions, especially about how any of your medications might interact with other medications, food, or alcohol, or how to best store your meds (in the fridge? out of sunlight? away from direct heat?) this is the time to ask them.
Quick check: do you need alcohol swabs or needles? A sharps container? Your pharmacist can help. Also, they may be able to take your filled sharps container when it’s full.
When you’re done with the questions, your pharmacist will tell you how much the prescription costs.
Once you’ve paid, you’re free to go!
Ordering and Re-Filling Online?
For most medications, once you are in a pharmacy’s system, you can order refills online. You can also call in to order a refill, and might not even need to speak to a person. At QueerDoc your prescriber almost always sends enough medication and refills to get you to your next appointment, even if your current prescription container says “no refills remaining” you should start by CALLING and TALKING to your pharmacy. In this day and age it sometimes feels weird to call and talk instead of using an automated system. But because your prescriptions may have been sent as a “new prescription” not a refill by your prescriber the automated system won’t see it. It is fastest for you to actually talk to a human at the pharmacy before messaging back and forth with your QueerDoc prescriber.
Refill timing: pharmacies can refuse to fill and insurance companies can refuse to pay for a refill request that happens too early. In many cases, a quick conversation can help you get a full or partial refill approved: are you travelling or otherwise not able to pick up a refill during the usual timing window? Did you lose any of your supply?
We hope this takes some of the mystery out of picking up your meds!
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