Schedule II Prescribing: Don't Be Pressured

In the January 18 issue, Psychiatric Practice and Managed Care contained a notice about a new regulation that the Drug Enforcement Agency (DEA) issued in November 2007. This regulation permits two refill prescriptions of Schedule II drugs to be written at the same time that the original prescription is written as long as the refill prescriptions are sequentially dated so that they cannot be filled until the appropriate time and do not exceed a total period of 90 days. Previously, refill prescriptions were banned for Schedule II drugs.

The new regulation is very helpful for physicians who, although they don't believe it is appropriate for the patient to have access to more than one month's supply of the Schedule II drug because of the potential for abuse, don't believe they need to see their patient every month and feel comfortable that the patient is continuing on the medication for the quarter.

The Managed Care Help Line received a call from a concerned APA member that makes it clear that writing prescriptions for Schedule II drugs needs to be explained more fully. The psychiatrist's patient, an attorney, was pressuring the doctor to prescribe a 90-day supply of the Schedule II drug the patient was on because his pharmacy plan would then charge only one copay rather than the three he would have to pay if the doctor wrote three sequential one-month prescriptions to cover a period of 90 days as permitted by the 2007 regulation.

The doctor's assessment was that the sequential prescriptions were the only safe way to prescribe for this patient, and he also believed that it was illegal to prescribe more than a month's supply of a Schedule II drug. However, when he checked with the patient's pharmacy plan, he was told this was not the case. In fact, although the DEA didn't allow refills of Schedule II drugs prior to December 2007, it never regulated how long a period a Schedule II prescription could cover (although some states may). According to the DEA, if a doctor deems it appropriate—that is, that there are no grounds for believing there will be diversion or abuse of the drug—there is nothing that forbids writing a prescription for a Schedule II medication for 90 days.

The psychiatrist who called the Help Line was very concerned about the pressure he was getting from his patient and the patient's pharmacy plan to prescribe in a way that he felt was unsafe. Although the law may allow a prescription to cover more than 30 days, it also requires that a physician not prescribe in a manner that will endanger the patient or pose a threat of diversion. If the psychiatrist has reason to believe that prescribing a higher number of pills poses any risk to the patient, the prescription should be written for the period deemed appropriate by the psychiatrist; the copay issue is irrelevant.

Unfortunately, the widespread pharmacy benefit policy of encouraging patients to order a 90-day supply of their medications by mail may create some tension with patients who will have to pay more for their medications, but the psychiatrist must always act in the best interests of the patient.

For information on this or other practice-related issues, contact the Managed Care Help Line at [email protected] or (800) 343-4671. ▪