Pharmacy Technician Certification Exam : Knowledge statements and Study GuideThe following are thesis and topics covered in

class but are commonly easily forgotten for the test

Information in this powerpoint presentation was gathered from previous exams and some other test material by me

Used the information here to supplement the knowledge you gained in class

Medications that require special handlingNitroglycerin, Nitroprusside, Paclitaxel, and

Fat Emulsions and amiodarone require IV infusion set that don’t have PVC or DHEP plasterizer.

Nitroprusside is light sensitive and the IV bag and IV set should be cover with a light opaque medium

Pradaxa (Dabigatran) is a anticoagulant used in place of warfarin for many condition. FDA in 2011 requires that the pharmacist dispense drug in the orginal container and the bottle be dated 60 days after opening

Medications that require refrigeration storageGeneric (Brand) Indication

Interferon 1B (Betaseron) IV vials

Multiple Sclerosis

Erthyromycin/Benozyl Peroxide (Benzamycin ) Gel

Acne

Alprostadil (Caverject) Vials Erectile Dysfunction

Estradiol/norethinedrone Patchs (Combipatch)

Contraception

Desmopressin (DDAVP) IV vials Diabetes insipidus

Etanercept (Embrel) vial kits Various Autoimmune diseases

Erythropoetin (Procrit, Epogen) RBC disorders

Generic (brand) Indications

Human Insulins Diabetes Mellitus

Human Growth Hormone (Humatrope)

Dwarfism, short stature in children

Lopinavir/Ritonovir (Kaletra oral sol)

HIV infection

Saquinavir (Fortovase) capsules HIV infection

Salmon Calcitonin (Miacalcin) nasal sypray

Osteoporosis

Octreotide (Sandostatin) Various endocrine disorders

Erthyromcyin Ethyl Succinate oral soln(EES oral solution)

Bacterial infections

Ribavirin/Interferon (Rebetron) HBV infections

Etoposide (Vepeside) capsules Cancer

Chlorambucil (Leukeran) tablets Cancer

Teriparatide (Forteo) Bone osteoporosis

Medication that must be Frozen for storageGeneric (Brand) Indication

MMR (measles, mumps and Rubella)

vaccination

Varivax (Varicella Zoster vaccine) vaccination

Most refrigerated medications should be refrigerated by the patient while taking at home. The most notable exception are insulin products, they may be keep at room temperature by the patient and they must be dated with a 28 day expiration from date vials are open

Medication that cause photosensitivity in Patients It’s the responsibility of the pharmacist to advise patients using

these drugs to wear protect clothing when in the day sunlight and using these drugs

This reaction does not always happen but when it does may cause a severe sun burn type reaction

Generic Brand

Doxycycline and other Tetracycline drugs

Various

Sulfonamide drugs Various

Retinoids Accutane and others

Sulfonylureas (Glipizide)

Glucotrol

Diuretics (Furosemide and HCTZ)

Lasix and Hydrodiuril

Dapsone Various

Outdated Medication WarningRemember that expired tetracycline products

are unsafe.Expired tetracycline products can cause

Fanconi’s syndrome, a disorder of the kidney that can produce dangerous electrolyte abnormalities in patients

When in doubt, discard these medications

Processing Rx ordersNo federal law states that a technician can not receive

a phoned in Rx; however some state prohibit this for phoned in new prescriptions

DAW codes helps insurance companies determine reimbursements for drugsDAW code are universal for all payersDAW 0 means generic productDAW 1 means MD wants brandThere are actually up to 8 codes, the DAW 5 code means

pharmacist selects brand but is willing to accept generic reimbursement

One of the most important elements on the dispensed product label is the initials of the pharmacist

All new patients to your pharmacy it is important to give them a copy of the HIPPA notice of privacy practices and to document that the patient received it; same holds true for doctor’s offices

Medicare Modernization Act of 2003 established the MTM, Medication therapy managementIntent was to reduce health care costs due to poor use of

medication by patientsPharmacists to help discover these problems and fix themAllows for billing of insurance for these services by

submitting CPT codesInsurance company use CPT code for billing (Current

procedural terminology)

Assisting the pharmacist with Insurance issues Medicare

Government insurance for those over 65 Patients young that 65 with certain disabilities Any age patient with end stage renal disease Part A=hospital Part B= office Part C= Medicare advantage Part D= Rx drug coverage

Part D was signed into law in 2003 Provide Rx coverage to seniors Premium depends on plan All plans have coverage up to $2,830/year after which the patient

covers all the cost of the drug After the patients reaches $4,550 in cost, Plan D kicks in a catastrophic

Rx coverage where it pays 100% of the cost This gap is called the “donuthole”

Affordable Care Act of 2010 (Obamacare)Provides financial relief to needy patients that fall into the

“donuthole”One time $250 rebate in 201050% reduction in cost of some drugs. The savings are

counted towards the donuthole7% discount on other drugs in the Part D

Medigap InsuranceSome patients have medicare and medicare supplemental

private insurance plans as secondary insuranceMedicare is the primary insurance, always bill medicare

first for any pharmacy related service; if medicare does not pick up all the cost then charge the balance to the secondary insurance

MedicaidGovernment health insurance for needy

people, pregnant women, teenagers, individuals who are legally blind

State splits the cost with the federal government

After a pharmacy submits a claim, we are paid at the MAC (maximum allowable cost) which is based on U&C’s (usual and customary costs publish by the drug companies)

Other government programsWorker’s Compensation

A worker injured on the job and that requires prescription medications will have no copay for drugs

Pharmacy files paperwork with employer to the state and federal governments

TRICARE is the health insurance plan that services uniformed armed services men and women

CHAMPVA (civilian health and medical program of the veteran administration) is insurance for permanently disable veterans and their family members

Adjudication Denial CodesWhen a pharmacy claim is rejected it could be

because of Refill too soonExpired coveragePrescribed quantity exceed limits of insurance plan

The most annoying areNDC not covered which means that insurance will not

pay for the drug who selected to fill the Rx; fix is to try another generic with a different NDC

Prescriber not covered: patient’s MD is not a part of the insurance network; patient need to change MD or pay for drug.

US FDA publishes the Orange BookOrange Book publishes ratings data on drug

therapeutic equivalence between drugsFor drugs to be consider therapeutically

equivalent, they must have a rate of AB or better

Drugs that have B ratings are not therapeutically equivalent and substitution between them is not permitted

FDA restricted drugsSome drugs have strong side effects such that the

FDA mandate special rules in the marketing of these drugs

Prior to 2007,FDA restricted drug program was called RiskMAP, risk mitigation action plans

After 2007 the new standards are called REMS, risk mitigation evaluation and mitigation strategies

For some drugs the REMS involves distributing PPI with each script (Oral Contraceptives, Hormone products (Estradiol), Accutane, and Inhaler products); others involve drug manufacturer to set up registries of patients, prescribers and pharmacies

REMS Special programsDrug REMS Special

requirementsFentanyl Transmucosal Systems (Actiq)

Transmucosal Immediate Release Fentanyl (TIRF) REMS

Registration of wholesalers and pharmacies to dispense products

Accutane (Isotrenoin) I Pledge REMS Patient and Prescribers must be enrolled, Female patients must have a negative pregnancy test and use two forms of birth control, Pharmacies must enrolled to order

Avandia products Rosiglitazone Medicines Access Program

Prescibers/patients must enroll and only specialty pharmacies stock it

Clozapine Clozaril National Registry Prescribers and patients must be enrolled; must provide ANC and WBC count to pharmacy, pharmacy must enroll to order

Procrit and Epogen and Aranesp

APPRISE REMS Prescribers must enrolled in program, patient must sign form to understand the risks

Alosetron (Lotronex) PPL (Prescribing program for lotronex)

Prescribers must enroll, patients must sign form, pharmacy to dispense with PPL sticker on RX

Paperwork requirementsIf pharmacy wants to file a claim to Medicare

for pharmacy services and/or durable medical equipment (DME) must use paper claim form, CMS 1500

DEA 222 for ordering CII drugs must be attached to invoice and filed for 2 years (Federal law). ALL controll substance invoices are saved for 2 years

All outpatient prescriptions for controlls must be saved for 2 years, after the date of last filling

Rotation of Pharmacy stockRotate medications with the longer expiration

behind those with the earliest medications on the shelf

With controlled substances, Federal law says if you group controlled substances together you must keep them in a locked area (like a locked cabinet). If you don’t want to lock the drugs, you must scatter the drugs among your regular stock. Lock or scatter-your choice

Commercially Prepared dehydrated powder medications for oral useProducts: Amoxicillin, Augmentin,

Clindamycin, Zithromycin, and may other antibiotics

Once mixing these antibiotics with water: a 14 day expiration is used under refrigerationExceptions: Augmentin (amoxicillin/clavulunate

potassium) and Biaxin (clarithromycin) are both 10 days

Remember these, very common

RadiopharmaceuticalsNuclear pharmacy provides radiopharmaceutical for

use of imaging, and therapy of cancerExamples: Indium 111 capromab for prostate cancer

imaging, Iodine 131 for thyroid cancer, and strontium 89 for metastatic cancer bone pain

In general preparation requires use of a BSC cabinet of type 3. This BSC is completely enclosed, often called “glove box” BSC.

Distance and speed principle is followed, aseptic technique is performed fast and with tongs (for distance) to minimize exposure to pharmacy personnel

StorageFederal law defines the following:

Room temperature= 59-86 F or 15-30 CRefrigeratored temperature= 36-46 F or 2-8 CFreezer temperature= below 32 F or 0 C

Extemperaneous CompoundingPharmacy makes a unique product dose form for a

specific patient, i.e acetaminophen 2% creamUSP 795 (not 797) says that expiration dating for

these products should not exceed 25% of the time remaining among the manufacturer drug product or six months into the future which ever is earliest

Any product where water is add to a solid dosage form is given 14 days under refrigeration unless published data state otherwise

Gelatin capsules come in sizes from 000 to 13.00o is the largest size13 is the smallest size

Prepacking and Unit dose systemsHelps in inventory management in hospitalsPrepacked and unit dose blister cards by law

are permitted to be return to inventory upon return

Expiration dating are one of two systems50% of the expiration date on the

manufacturer drug or 1 year whichever is sooner (my hospital uses this)

USP 795 guideline: 25% or six months whichever is sooner

Combat Methamphetamine Act of 2005Products containing ephedrine or pseudoephedrinePseudoephedrine products include: Pseudofed, formally in

DayQuil and NyquilUsed to make illegal crystal meth or “ice” on the streetCurrently ephedrine based diet pills (uses outside allergy,

asthma, and traditional chinese use) are banned by the FDA (since 2006).

Aside these, all these products are kept behind the counter in the pharmacy.

A log book must be keepID is required to be verified by the pharmacistNo more than 3.6 grams/day for any one personNo more than 9 grams/month for any one person

Medications that should not be prepacked (unit dose)The standard unit dose prepackage machine as a mechanical dial

that rotates between metal plates that are heated to high temperatures. Oral dose forms are placed on the dial and the metal plates seal the blister pack material around the medication with heat

Some medications should not be prepacked with a standard machine because the machine will become contaminated with dust particles from these drugs At times a dedicated machine can be used for some of these drugs

Common highly allergic potential drugs include: Penicillins, Cephalosporins, sulfa drugs

Moisture Sensitive medications Pyridostigmine (Mestinon) Prasugrel (Effluent) Emtriva Most orally melting tablets : Risperdal M

Capsules Most gelatin capsules will melt when exposed to heat Ritonovir Omega 3 Fatty Acids capsules

Chemotherapy drugs and Teratogenic drugs Chlorambucil (Leukeran) Cyclophosphamide (Cytotaxan) Cyclosporin (Gengraf) Bosentan (Tracleer): Pregnancy category X

In general, always inquire about the pregnancy rating and the cytotoxic potential of drugs before you are asked to prepack anything. (especially if you are a woman of childbearing potential)

For a more complete listing visit: http://

www.ashp.org/s_ashp/docs/files/MedNO_unit-dosedpackage.pdf