“Patient Requests 90 Day Supply”

The pharmacists also described being held to increasingly strict performance metrics, such as how quickly they answered the phone, the portion of prescriptions that are filled for 90 days rather than 30 or 60 days (longer prescriptions mean more money up front) and calls made urging people to fill or pick up prescriptions.

- The New York Times 12/3/23

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.