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Refill policy sample

OverviewThe following pages contain details on how to administer our automatic refill policy. Our intentis to streamline, standardize and reduce waiting times for refills of medications. The policyemphasizes standard times and rules for refills that should result in improved safety and qualityof care.
The medications are listed by generic and trade names and have attached a time during which thepatient must have had an office visit in order to obtain an automatic refill from nursing staff. Ifthe patient has not been seen within this time frame, a one-month supply of medication may besent by nursing staff to the pharmacy of the patient’s choice, but the patient must schedule anoffice visit within that month before any additional refill is issued.
Under the following circumstances, an automatic, nurse-approved refill may NOT be given. The
request should be forwarded to the treating physician in the form of a phone note:
1) There is a NO SHOW as the most recent “visit” in the chart.
2) A Trinity Clinic Whitehouse physician is not the original prescribing physician
3) The patient insists on doctor’s review for a denial based upon protocol rules
4) The medication is in one of the following classes (these medications do not appear on the
Please note: for antihypertensive medications, the patient must have had an in-person or virtual
office visit within the past 6 months AND their last blood pressure reading in the flowsheet
within that past 6 months must be less than 140 systolic AND less than 90 diastolic. This will
ensure that patients are not missing their short-term follow-up visits for blood pressure
medication titration.
If at any time there is a question about how to apply the policy, the default is to send thematter/question to the treating physician in the form of a phone note.
Melissa Gerdes, M.D.
Janet Hurley, M.D.
Amy Mullins, M.D.
Donna Judalet, LVNWendy LaFaitt, LVNJeannie Sigler, MA My clinical staff, which includes LVN's and Medical Assistants, have my authority to refill thefollowing medications as a standing delegated order: The medications listed here may be renewed for a 3-month supply for adults (>/=18 yrs of age), provided they have been seen in the office within the last 3 months, immediatelyupon receipt of the request.
The medications listed here may be renewed for a 6-month supply for adults (>/=18 yrs of age), provided they have been seen in the office within the last 6 months, immediatelyupon receipt of the request.
The medications listed here may be renewed for a 1-year supply for adults (>/= 18 years), provided they have been seen in the office within the last 12 months, immediately uponreceipt of the request.
Drugs are listed alphabetically here:
Acarbose
6 mo Brand
Accupril
Quinapril HCl
6 mo Brand
Accuretic
Hydrochlorothiazide
ACE Inhibitors
ACE Inhibitors
Rabeprazole sodium
Activela
Estradiol / Norethindrone Acetate
Risedronate sodium
3 mo Brand
Actoplus Met
Metformin HCl / Pioglitazone HCl
3 mo Brand
Pioglitazone HCl
Acyclovir Ointment or Oral
Adapalene
Differin
Fluticasone propionate /
6 mo Brand
Advair Diskus
Salmetrol Xirafoate
6 mo Brand
Lovaststin / Niacin
6 mo Brand
Flunisolide
Loratadine
Albuterol
Ventolin / Proventil
Albuterol Sulfate /
Duoneb / Combivent
Ipratropium Bromide
6 mo Brand
Aldactone
Spirolactone
6 mo Brand
Methyldopa / Methyldopa HCl
Alendronate Sodium
Alfuzasin HCl
Uroxatrol
Algestone Acetophenide
Progestrone
Fexofenadine HCl
6 mo Brand
Allopurinol
Zyloprim
Almotriptan
Estradiol
6 mo Brand
Ramipril
6 mo Brand
Altoprev
Lovastatin
Amantadine HCl
Symmetrel
3 mo Brand
Glimepiride
Amitriptyline
Elavil / Vanatrip
Amlodipine Besylate
6 mo Brand
Naproxen
6 mo Brand
Flurbiprofen
6 mo Brand
Aquazide H / Microzide
Hydrochlorothiazide
6 mo Brand
Donepezil HCl
Armour thyroid
Thyroid Dessicated
6 mo Brand
Arthrotec
Diclofenac sodium / Misoprostol
Astelin Spray
Azelastine HCl
6 mo Brand
Atacand / Atacand HCT
Gen. Candesartan Cilexetil / Hydrochlorothiazide
6 mo Brand
Hydroxyzine HCL
6 mo Brand
Atenolol
Tenormin
Atorvastatin Calcium
6 mo Brand
Atrovent
Ipratopium Bromide
6 mo Brand
Hydrochlorothiazide / Irbesartan
3 mo Brand
Avandamet
Metformin HCl / Rosiglitazone maleate
3 mo Brand
Rosiglitazone Maleate
6 mo Brand
Ibesartan
Dustasteride
6 mo Brand
Almotriptan
Nizatidine
Azelastine HCl
Astelin Spray
6 mo Brand
Azmacort
Triamcinolone Acetonide
Beclamethasone
Becolvent
Beclometasone Diapropionate
Vanceril
6 mo Brand
Becolvent
Beclamethasone
Benazepril HCl
Lotensin
Benazepril HCl / Amlodipine Besylate
Benazepril HCl / Hydrochlorothiazide
Lotensin HCT
6 mo Brand
Olmesartan Medoxomil
6 mo Brand
Dicyclomine HCL
Benzamycin
Erythromycin / Benzoyl Preoxide
Benzonate
Tessalon Perles
Betamethazone
Celestone
Betaxolol HCl
Keralone
Guaifenesin
Bisoprolol Fumarate / HCTZ
6 mo Brand
Blocadren
Timolol Maleate
Ibandronate Sodium
6 mo Brand
Brethair
Terbutaline
Bromocriptine Mesylate
Parlodel
Budesonide
Rhinocort
Budesonide
Pulmicort
Bupropion HCl
Wellbutrin SR
3 mo Brand
Exenatide
6 mo Brand
Verapamil HCl
Calcitonin
Miacalcin
Candesartan Cilexetil
Gen. Candesartan Cilexetil / Hydrochlorothiazide Brand
Atacand HCT
6 mo Brand
Captopril
Captopril
Carafate
Sucralfate
Carbamazepine
Tegretol
6 mo Brand
Nicardipine HCl
Cardiotex RX
Cardiotex RX
Cardiotex RX
Cardiotex RX
6 mo Brand
Cardizem CD
Diltazem HCl
6 mo Brand
Doxazosin mesylate
Carvedilol

Source: http://blogs.aafp.org/fpm/transformation/resource/RefillPolicySample.pdf

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