Legend / Non-legend Drugs

CoffeeRTC, BSN, RN · Jun 16, 2014

What are legend drugs?

MunoRN, RN · Jun 16, 2014

Since payers (insurance, medicaid, etc) typically reimburse for both legend and non-legend drugs at similar rates, I'm not sure why it would help to reduce non-legend drugs.

It sounds like they mean "reduce non-formularly drugs". Facilities typically try to narrow the variety of drugs they carry or provide, for instance, instead of providing protonix and prilosec and prevacid they just narrow that down to a single proton pump inhibitor, so whatever PPI they have ordered, they get protonix, for instance. The price that facilities pay for drug is often based on the amount they purchase; the more they buy of a particular drug, the less they pay, so it makes more sense to combine multiple similar drugs.

CapeCodMermaid, RN · Jun 16, 2014

I don't know what insurance companies you're used to dealing with, but most of them do NOT pay for over the counter meds.

txredheadnurse, BSN, RN · Jun 22, 2014

To expand on what a PP stated reduce the overall variety of non legend drugs stocked in each facility. By that I mean is it really necessary to have so many different strengths and types of calcium (with and without vitamin D), or multivitamins or GI tract drugs, of single vitamins such as Vit D, E, C or GI tract meds. In addition be careful of purchasing very large bottles (like 500 or 1000 count) of OTC analgesics (unless it something like EC aspririn 81 mg) because those expire before all the pills are used. Side note in many states all non legend drugs stored on a med cart must be dated when opened and expire within one year of opening or sooner if the manufacturer expiration dates precedes the opening date ending time. Those gigantic bottles end up being tossed long before all the pills are used.

I would suggest obtaining the last two non legend drug orders from each of your facilities and look over them to see what is being ordered. Identify the commonalities in the orders then further break it down it down as to different types and strenghts being ordered etc. It is usually pretty simple to decide from there that it is best to order only 250 mg Vit C for instance instead of 250 mg and 500 mg and 1000 mg and so on from there. In other words only stock the lowest common strength and the least complicated formulation. Prepare a company formulary list from that and ask your DONs to have their medical directors to sign off on that. Then make a new ordering form that only lists the "formulary" strengths on it and have your DONs distribute those to the appropriate staff and in service accordingly. I would suggest that if a doctor insists on some non legend drug not on the formulary then the DON or their delegate has to approve it. I would also suggest that the DONs keep a running list of those providers who always seem to order large amounts of meds not on the suggested use list or large amounts of non legend drugs in general. Some of the EMR systems have the ability to generate data bases per physician of most expensive meds, largest number of meds prescribed etc. Many prescribers are cost conscious nowadays but not all are or they have the misperception that Medicare pays for all meds for the entire time of admission to a SNF which of course it not the case. And even when a resident is in that payment category all those meds come out of that lump sum payment so excessive amounts of non legend drugs can be damaging to maintaining a profit. It is not evil to make a profit because if a facility doesn't ultimately no one gets paid or can afford to stay open. I mention the list because I have had facilities in the past that when they say the concrete evidence of prescribing patterns of some docs had their medical directors have a very focused discussion with those prescribers.

There is consideration of reducing the amount of storage space used for non legend drugs in the med rooms, on the med carts, reducing the number of errors because someone in a hurry picked up the calcium carbonate 500mg with Vit D 200IU instead of the calcium carbonate 600 mg with Vit D 400IU, wrong type of multivitamin with minerals and so forth. Plus more room on med carts is a good thing. I have opened more than one med cart in my day and simply been staggered at the sheer volume of non legend drugs stuffed in there....like 60 or more bottles. Even if no one makes any med errors from using the wrong non legend drug simply having to constantly hunt through that sea of bottles is a time waster.

I hoped this helped.

txredheadnurse, BSN, RN · Jun 22, 2014

I meant to include this also. After a master ordering list is obtained then someone will need to amend the non legend drugs for each resident to reduce quantity etc. I suggest doing this whenever the orders are reconciled on a monthly basis. Start with the extended care/intermediate care residents and do so many per week/month. The new skilled admits can be handled the way I have seen a few facilities do in the past. They had a facility "formulary" and would substitute some drugs for others upon admission. An example it seems like every single admit from a hospital comes to the facility on Protonix for instance. The facility would have on their "formulary" replace with prilosec otc.

A way to assist your facilities with maintaining adherence to the preferred use list is devise a tool or process that incorporates a review of all non legend drugs during each consolidated orders review.

Again I hope that helps. My beloved doggie has been bringing me toys to play with while I am typing this so any typos or muddy thoughts are her fault lol.