Your Questions Answered

Questions have been collected from previous COVID-19 webinars and emails received by IPA staff. IPA strives to find answers to all of your pharmacy-specific questions regarding COVID-19. Questions and answers will be updated each week and as changes arise. Updated May 28, 2020.

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Topics:
Iowa Specific
Workforce Concerns

Pharmacy Operations
PBM/Billing Concerns

Professional Licensing

Clinical Questions


Iowa Specific
:

How does IPA plan on keeping its members informed?

What actions (related to pharmacy) have been taken by the Governor under Executive Order?
  • Temporarily suspended the regulatory provisions which prohibit the practice of pharmacy by a pharmacist whose license is inactive or lapsed within 5 years, or by a pharmacy technician trainee who is unable to become nationally certified and whose trainee registration expires between March 18, 2020 and May 31, 2020.
  • Temporarily suspended the provisions requiring applicants for a pharmacist license to complete all components in Iowa within a period of one year from the date the candidate passed the initial component.
  • On April 2, 2020, the Governor’s extension to the Emergency Proclamation allowed the Board of Pharmacy to provide pharmacies with guidance on pharmacists performing therapeutic substitution. See Section Thirty-Three of the Emergency Proclamation(April 2, 2020)
  • Governor Reynolds signed a new proclamation continuing the Public Health Emergency until June 25, 2020. Therapeutic substitution by a pharmacist without prior consent by the prescriber will continue to be temporarily permitted. The prohibition of practice by a pharmacist whose license is inactive or lapsed within five years, or by a pharmacy technician trainee who is unable to become nationally certified due to closed testing locations is also suspended for the duration of the proclamation. The Iowa Board of Pharmacy has outlined and responded to Governor Reynold’s proclamation as it pertains to pharmacy. (May 26, 2020)

What actions have been taken by the Board of Pharmacy?

Where should pharmacies note they are performing COVID-19 testing? 
How have the Iowa Board of Pharmacy’s (BOP) USP 800 requirements/deadlines on construction changed due to the pandemic? 
  • The BOP still expects compliance. Facilities with issues should contact BOP if in need of extended time.
What if a hospital’s 503B compounding source goes from non-sterile to sterile compounding? Does the hospital need to contact the BOP? 
  • To increase the supply of critical medications of hospitalized COVID-19 patients, the FDA announced flexibilities for 503B outsourcing facilities and 503A compounding pharmacies that are compounding these medications for hospital use.  
  • In response to these flexibilities, the Iowa Board of Pharmacy (BOP) is only requiring 503A compounding pharmacies to notify the BOP of their intent to compound medications for hospital use. 503B outsourcing facilities are not required to notify the BOP.  

How should pharmacists handle prescriptions for investigational medications for COVID-19 prophylaxis?

What guidance is available for children’s medications left at school?
  • The Iowa Board of Pharmacy has provided guidance to school nurses as to what to do with medications left at schools. The BOP’s guidance is in compliance with the United States Environmental Protection Agency’s Enforcement Discretion Policy for COVID-19 Pandemic. (March 26, 2020) As pharmacies may receive questions from parents, please see guidance:
  1. Ask the parent or legal guardian to come to the school to pick up the medication from the nurse or school administrator.
  2. If the parent can't go to the school to get the medication, reach out to the pharmacy, which dispensed the medication to see if the pharmacy would be willing to come to the school to collect the medication on behalf of the patient. Then, the pharmacy could elect to either deliver the medication to the patient or have the medication at the pharmacy for the parent(s) to pick up.
  3. If the pharmacy isn't willing to come to pick up the medication from the school, see if the nurse is willing to bring the medication to the pharmacy for the pharmacy to deliver or have available for patient pick up.
  4. If the pharmacy isn't willing to have any involvement, allow the nurse to mail to the patient (asking that they stuff cotton or tissues into the bottle(s) to limit the sound of pills) utilizing some sort of delivery confirmation or signature required.
Does the TestIowa program include antibody testing? 
  • No, the TestIowa program is only offering diagnostic testing at this time.


Workforce Concerns:

What is recommended for pharmacy employees exposed to COVID-19?

  • Guidance has been issued by the CDC for healthcare workers exposed to the virus here(Updated May 23, 2020)
How does paid leave and FMLA apply to the pharmacy workforce?
  • The US Department of Labor released and FAQ related to the Family First Response Act which includes pharmacy as healthcare providers.
Were pharmacists included in the hazardous pay legislation?
  • A proposal released by U.S. Senate Democrats entitled the “Heroes Fund”, would provide a flat hazard pay increase of $13 per hour, capped at $25,000 for workers earning less than $200,000 annually for a number of different medical professionals and essential workers, including pharmacists. The Heroes Fund may be a part of the next coronavirus relief bill being prepared by the both the U.S. House and Senate. (April 7, 2020)


Pharmacy Operations:

Should pharmacies close their front doors and only provide drive-up/delivery/curbside pickup?

  • This is up to the discretion of each pharmacy.
  • Some pharmacies are designating high-risk only in-store hours.
  • See Best Practices from the CDC. (Updated May 28, 2020)

What about signature capture?

  • Guidance has been issued from CMS (Part D) (March 20, 2020), Iowa Medicaid (March 31, 2020), and Wellmark (March 20, 2020) to allow pharmacies to write “COVID” on the signature capture, so that patients do not have to sign to pick up their prescriptions.  

What about crash carts that have been in the room of infected patients?

  • No official guidance currently.
  • Some hospitals are keeping them in the hallway to disinfect each product prior to reuse.
  • Crash carts in New York hospitals are staying outside of patient rooms. Pharmacists typically are the ones who stay with the cart. Medications are individually wrapped in plastic bags. The medications that come back after the code are placed in a separate isolation room in the pharmacy and disinfected with purple top disinfectant wipes.

What if your pharmacy experiences a staffing shortage during this time?

  • Visit IPA’s Relief Effort List of pharmacist, technician, and student volunteers willing to temporarily help another practice site.
If a licensed pharmacy is not currently registered as an experiential site, is there a temporary process to quickly become an experiential site for students?
  • Onboarding can be relatively quick. Pharmacies interested in becoming an experiential site, please contact the experiential education offices at Drake University COPHS (cheryl.clarke@drake.edu) and University of Iowa College of Pharmacy (jennifer-seyfer@uiowa.edu).
  • Hospital pharmacy sites are greatly needed. 

Where can pharmacists learn of current drug shortages?

  • The American Society of Health System Pharmacists’ Drug Shortages webpageThis members-only benefit is now available to ALL on ASHP’s website.
Can Medication Therapy Management services be provided over the phone or via telehealth?
  • OutcomesMTM has provided participating pharmacies with additional guidance on continuing to perform Comprehensive Medication Review for their patients over the phone.
Will DSCSA track and trace requirements be relaxed to allow pharmacy to pharmacy product purchasing due to drug shortages?
  • Under the national emergency proclamation, DSCSA is temporarily suspended related to COVID-19, which may allow pharmacy to pharmacy product purchasing.
What are some staffing model recommendations?
  • Some hospital systems have several ‘waves’ or ‘groups’ of pharmacy staff complete tasks in rotations in an effort to minimize staff exposure, and ensure adequate staffing if one ‘group’ gets exposed to COVID-19. (This can be applied in other pharmacy settings also.)
What guidance is available on PPE conservation due to shortages?
  • Iowa Board of Pharmacy guidance for pharmacies (March 9, 2020)
  • CDC guidance on optimizing PPE supply
  • USP Response to Shortages of Garb and PPE for Sterile Compounding During COVID-19 Pandemic


PBM/Billing Concerns:

Are there audit protections for pharmacies unable to obtain a signature from patients at pick-up?

What changes have been implemented by Iowa Medicaid to assist pharmacies during this time?

  • Informational Letter No. 2119-MC-FFS-CVD (March 19, 2020)
    • Allows early refills
    • Allows 90-day fills
  • Due to shortages of the preferred albuterol HFA inhaler, more products will be added to the Preferred Drug List effective March 27, 2020. View the fax blast here(March 23, 2020)
  • Informational Letter No. 2123(March 31, 2020)
    • Existing PA’s extended through June 30
    • Member copays suspended
    • MCO audits suspended
    • Signature capture waived
    • COD survey deadline extended

What changes have been implemented by Wellmark to assist pharmacies during this time?

  • Allowing early refills and 90-day fills. See COVID-19 and Emergency Declaration Override Procedures from CVS Caremark for override codes and instructions. (March 11, 2020)
  • Approving overrides for drugs (specific to each pharmacy) if there are supply chain issues. This will require a call to the CVS/Caremark helpdesk – tell the help desk this is specific for Wellmark patients.
  • Allowing all forms of short-acting beta-agonist inhalers to be processed. This will not require a call the helpdesk. Wellmark members will not be responsible for additional charges if they are provided with a non-formulary medication.
  • CVS/Caremark has agreed to suspend all voluntary pharmacy audits in the State of Iowa.
  • All current PAs will be extended through July 31, 2020.
  • Telehealth visits performed by all healthcare providers are being reimbursed at the same rate as in-person visits.
  • Wellmark is waiving all patient cost-sharing requirements for COVID-19 testing and treatment when seeking care from an in-network provider. Prescription copays are not included in this waiver as there are no medications with an FDA indication for the treatment of COVID-19 yet. This waiver is effective February 4 through at least June 16, 2020. To learn more, read the Wellmark news release. (April 1, 2020)
How are pharmacists handling Medicare Part D plans in regards to albuterol HFA preferred products? 
  • The Board of Pharmacy guidance allows therapeutic substitution pursuant to formulary management.
Is Iowa Total Care allowing 3 month supplies of SSRI’s, SNRI’s, and other mental health medications? 
  • Allowance is given for up to a 90-day supply for preferred medications on PDL or a non-preferred product with a PA in place.
Has there been any further action from Iowa Total Care in regards to helping with copay of telehealth visits?  
  • Iowa Total Care has waived patient copays for telehealth visits.
How are the MCOs and their PBMs handling payment for prescriptions written by out-of-network telehealth providers at point of sale? 
  • Iowa Total Care - IME has established a process for MCOs to request expedited enrollment for providers including pharmacies. Obviously, for point-of-sale prescriptions, even expeditious enrollment will result in a delay. However, there is no requirement for providers to be enrolled with ITC. During the public health declaration, if a provider, including a pharmacy, is not contracted with ITC, they will be considered in network. 
  • Amerigroup - If members do not have appropriate access to network doctors Amerigroup will authorize coverage for out-of-network doctors as medically necessary. If a prescription claim rejects at point of sale, pharmacies should call the IngenioRx pharmacy helpdesk at 1-833-236-5925 to request approval. In addition, pharmacists may advise patients to seek care from Amerigroup’s telehealth provider, LiveHealth Online
How are payers and their PBMs adjusting their MAC rates for pharmacies unable to secure the lowest cost generics due to intermittent drug shortages? 
  • Iowa Medicaid: Amerigroup & Iowa Total Care - The MCOs are required to reimburse pharmacies no less than the AAC rate updated weekly by Myers & Stauffer. Pharmacies are encouraged to complete the AAC rate review request. Based on the findings of the research, claims may be updated retroactively.
  • Wellmark BCBS (CVS Caremark) - Pharmacies are encouraged to submit a MAC appeal through the network pharmacy portal. 
Have Wellmark or Iowa Medicaid recognized pharmacists as the ordering provider for COVID-19 tests, and will they pay accordingly? 
  • Wellmark BCBS recognizes that pharmacists are qualified to order and administer COVID-19 tests that are approved by the FDA pursuant to the HHS guidance released on April 8, 2020. 

  • Iowa Medicaid does not have any information on payment for pharmacists ordering and testing patients for COVID-19.  


Professional Licensing:

What exceptions are being made for pharmacy students?

  • Check the Iowa Board of Pharmacy’s press releases here for the most up to date information.
What exceptions for pharmacy technicians seeking certification will be made?
  • Check the Iowa Board of Pharmacy’s press releases here for the most up to date information.
Will a FD258 card for fingerprints work for licensure requirements since many sheriff’s offices are closed to the public?
  • The Board’s provision requiring all pharmacist applicants to provide an FBI background check has been suspended through the Governor’s proclamation signed on March 22, 2020.
  • Background checks will be waived for the interim while fingerprint sites are unavailable, and the proclamation is effective. Students graduating this year and applying for pharmacist licensure that fulfill all other requirements will not be prevented from becoming licensed.
  • When the proclamation expires, the Board will reach out to these applicants to complete the background check requirement.
Do emergency pharmacists licenses apply only to Iowa graduates?
  • Graduates from out-of-state are eligible for emergency licensure in Iowa as long as they will be participating in an ACPE accredited residency program in 2020. See guidance from the Iowa Board of Pharmacy. (May 12, 2020)
 

Clinical Questions:

What are the risks and benefits of using hydroxychloroquine/chloroquine and azithromycin?

What guidance exists on using MDI’s instead of nebulized medications?
  • View Mount Sinai Health System resources.
What medications should hospitals and ambulatory care pharmacies work to secure in preparation for COVID-19 patients?
  • Hospital leadership should work to secure the following medications in preparation for COVID-19 medications through local health department and CDC stockpiles, having a dedicated staff member monitor the drug supply chain on an hourly basis, and if possible, have medications shipped to a centralized location for further distribution in order to ensure proper tracking of supplies.
  • Treatment: Hydroxychloroquine/chloroquine, azithromycin
  • Intubation/ventilated patient medications: fentanyl, hydromorphone, neuromuscular blockers
  • Respiratory distress medications: MDI medications are preferred in order to reduce aerosolization – albuterol and Atrovent inhalers are difficult to secure due to shortages
  • Possible medications without evidence of use: tocilizumab, IL-6 inhibitors, anakinra
Are there guidelines on duration of treatment for COVID-19 patients with hydroxychloroquine/chloroquine and azithromycin?
  • View Mount Sinai Health System resources.
How can hospitals secure remdesevir for COVID-19 patients?
  • Remdesevir is only being administered through clinical trials. Hospitals will need to enroll as a trial site with Gilead in order to begin providing their patients with remdesevir.
Are there any in-patient anticoagulation protocols for COVID-19 patients? Examples of Anticoagulation Protocol for COVID-19 Patients: