1. Pharmacy Technician Certification Exam : Knowledge statements and Study Guide The 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

2. Medications that require special handling Nitroglycerin, Nitroprusside, Paclitaxel, and Fat Emulsions and amiodarone require IV infusion set that dont 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

3. Medications that require refrigeration storage Generic (Brand)Indication Interferon 1B (Betaseron) IV vialsMultiple Sclerosis Erthyromycin/Benozyl Peroxide (Benzamycin ) Gel Acne Alprostadil (Caverject) VialsErectile Dysfunction Estradiol/norethinedrone Patchs (Combipatch) Contraception Desmopressin (DDAVP) IV vialsDiabetes insipidus Etanercept (Embrel) vial kitsVarious Autoimmune diseases Erythropoetin (Procrit, Epogen)RBC disorders

4. Generic (brand)Indications Human InsulinsDiabetes Mellitus Human Growth Hormone (Humatrope)Dwarfism, short stature in children Lopinavir/Ritonovir (Kaletra oral sol)HIV infection Saquinavir (Fortovase) capsulesHIV 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) capsulesCancer Chlorambucil (Leukeran) tabletsCancer Teriparatide (Forteo)Bone osteoporosis

5. Medication that must be Frozen for storage Generic (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

6. Medication that cause photosensitivity in Patients Its 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 GenericBrand Doxycycline and other Tetracycline drugs Various Sulfonamide drugsVarious RetinoidsAccutane and others Sulfonylureas (Glipizide)Glucotrol Diuretics (Furosemide and HCTZ) Lasix and Hydrodiuril DapsoneVarious

7. Outdated Medication Warning Remember that expired tetracycline products are unsafe. Expired tetracycline products can cause Fanconis syndrome, a disorder of the kidney that can produce dangerous electrolyte abnormalities in patients When in doubt, discard these medications

8. Processing Rx orders No 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 drugs DAW code are universal for all payers DAW 0 means generic product DAW 1 means MD wants brand There 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

9. 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 doctors offices Medicare Modernization Act of 2003 established the MTM, Medication therapy management Intent was to reduce health care costs due to poor use of medication by patients Pharmacists to help discover these problems and fix them Allows for billing of insurance for these services by submitting CPT codes Insurance company use CPT code for billing (Current procedural terminology)

10. 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

11. Affordable Care Act of 2010 (Obamacare) Provides financial relief to needy patients that fall into the donuthole One time $250 rebate in 2010 50% reduction in cost of some drugs. The savings are counted towards the donuthole 7% discount on other drugs in the Part D Medigap Insurance Some patients have medicare and medicare supplemental private insurance plans as secondary insurance Medicare 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

12. Medicaid Government 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&Cs (usual and customary costs publish by the drug companies)

13. Other government programs Workers 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

14. Adjudication Denial Codes When a pharmacy claim is rejected it could be because of Refill too soon Expired coverage Prescribed quantity exceed limits of insurance plan The most annoying are NDC 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: patients MD is not a part of the insurance network; patient need to change MD or pay for drug.

15. US FDA publishes the Orange Book Orange Book publishes ratings data on drug therapeutic equivalence between drugs For 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

16. FDA restricted drugs Some 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

17. REMS Special programs DrugREMSSpecial requirements Fentanyl Transmucosal Systems (Actiq) Transmucosal Immediate Release Fentanyl (TIRF) REMS Registration of wholesalers and pharmacies to dispense products Accutane (Isotrenoin)I Pledge REMSPatient 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 productsRosiglitazone Medicines Access Program Prescibers/patients must enroll and only specialty pharmacies stock it ClozapineClozaril National RegistryPrescribers and patients must be enrolled; must provide ANC and WBC count to pharmacy, pharmacy must enroll to order Procrit and Epogen and AranespAPPRISE REMSPrescribers 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

18. Paperwork requirements If 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

19. Rotation of Pharmacy stock Rotate 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 dont want to lock the drugs, you must scatter the drugs among your regular stock. Lock or scatter-your choice

20. Commercially Prepared dehydrated powder medications for oral use Products: Amoxicillin, Augmentin, Clindamycin, Zithromycin, and may other antibiotics Once mixing these antibiotics with water: a 14 day expiration is used under refrigeration Exceptions: Augmentin (amoxicillin/clavulunate potassium) and Biaxin (clarithromycin) are both 10 days Remember these, very common

21. Radiopharmaceuticals Nuclear pharmacy provides radiopharmaceutical for use of imaging, and therapy of cancer Examples: 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

22. Storage Federal law defines the following: Room temperature= 59-86 F or 15-30 C Refrigeratored temperature= 36-46 F or 2-8 C Freezer temperature= below 32 F or 0 C

23. Extemperaneous Compounding Pharmacy makes a unique product dose form for a specific patient, i.e acetaminophen 2% cream USP 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 size 13 is the smallest size

24. Prepacking and Unit dose systems Helps in inventory management in hospitals Prepacked and unit dose blister cards by law are permitted to be return to inventory upon return Expiration dating are one of two systems 50% 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

25. Combat Methamphetamine Act of 2005 Products containing ephedrine or pseudoephedrine Pseudoephedrine products include: Pseudofed, formally in DayQuil and Nyquil Used to make illegal crystal meth or ice on the street Currently 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 keep ID is required to be verified by the pharmacist No more than 3.6 grams/day for any one person No more than 9 grams/month for any one person

26. 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

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