Whose Prescription is That Anyway?

I recently took a prescription for pregabalin/Lyrica to my pharmacy.  Lyrica is a controlled substance, so I hand carried the paper prescription myself.  My pharmacist took one look at the prescription, consulted her computer, and quickly advised it could not be dispensed as written, as my insurance would only cover Lyrica in a limited quantity format — in my case, two thirds of the prescription could be covered under my insurance. 

So, I took what I could get and decided to tell my prescribing physician what had happened.  Indeed, my pharmacist had taken me aside when I was picking up the Lyrica prescription to note, again, that it had not been dispensed as written. My prescribing physician was sanguine and told me to proceed with the lyrica build up — that we could address doses on the higher end if and when we got to it.

Nonetheless, I was intrigued by the question of who can change a doctor's script once it is submitted.  I began to ask about the basis for the quantity limitations. I am not certain I got the story straight, but here is what I think I learned.

It turns out that Lyrica's controlled substance status is the tail wagging the dog more than anything else.  A Lyrica prescription can be altered in certain limited ways, including change of quantity and dose.  On the federal level, Lyrica is a Schedule V controlled substance. Pregabalin is known as the "new Valium" in the U.K. or by its nickname "Budweiser". On the state level, California's Health and Safety Code restricts how a pharmacist may dispense a Schedule V controlled substance.

That means appropriateness of use is at issue, particularly for patients with a history of prescription drug abuse, and appropriateness of dose is also an issue. And I learned that quantity limitations on prescription drugs are quite common.

But what drives the quantity limitation is harder to identify. Many plans appear to be relying on CDC guidelines for the prescription of opioids.

Why pin it on the insurance company?  Because they have brought their drug formulary into their best understanding of  dispensing guidelines found in federal and state law as well as CDC Guidelines.

With so many cooks in the Schedule V dispensing broth, I have to wonder about liability if anything goes wrong. All of this is further muddied by Lyrica's high dispensing cost, surely a further incentive to limit both access and quantity.