by Peter Bridgman M.D.
Brunswick, Maine

I have a neurology practice in coastal Maine. Last week I was looking through lab results sent by fax, and I saw that one of my patients with epilepsy had a low Depakote level. Puzzled, I called him up and asked what was going on. I mentioned that he had always had a therapeutic level when the blood tests had come in before. He said that he had gone a few days without his medication when the refill had come late in the mail. To save money he had ordered his medication from a popular mail order pharmacy. He was lucky that he did not have seizures during the time when he was out of medication!

I’m sure that this scenario is happening more frequently now that more patients are getting their medications from mail order pharmacies. Just like any change in the therapeutic plan, there has to be some sort of backup if the plan is not working. Here are some guidelines for using mail order pharmacies:

1. Make sure when you receive your shipment that it is complete, and the entire 30 day or 90 day supply has arrived. Mark on your calendar when you will be down to a two week supply so that you can order, and receive your next shipment before you run out. Your insurance may require you to use a certain percentage of the supply before you order your next refill.
2. Mail order or online pharmacies usually have toll free 1-800 numbers to call if you have questions. The website may also have an email option for ordering medications, or you can register, and manage your prescription ordering by using the online forms.
3. If you are not sure which mail order or online pharmacy to use, you can check the list of accredited online pharmacies at www.nabp.net This site is maintained by the National Association of Boards of Pharmacy. Check with your insurance plan to make sure that you are getting the best discount for ordering 90 day supplies. Some insurance plans require enrolled patients to use specified mail order pharmacies. Here in Maine, for example, Medicaid patients have no copays for 90 day supplies from the preferred “I Care” mail order pharmacy.
4. Most importantly, have a backup plan if your refill shipment is late. Do not skip your medication doses! Even a few days off antiseizure medications can cause the recurrence of severe seizures or even life-threatening Status Epilepticus. If a shipment is late, call the doctor’s office and ask for a “bridge” refill from a local pharmacy to tide you over until the mail order refill arrives. The doctor’s office might in some cases have samples or generic counterparts available to help in this situation.
5. As a last resort, if you are out of medication over a holiday weekend when retail pharmacies are closed, you can sometimes get an emergency supply from a hospital emergency room. This requires that you make a visit to the ER to speak briefly with the nurse and the doctor on ER duty to make sure that you get an adequate supply to last until the next business day. You may have a substantial copay for this type of visit, so this option should be a last resort.
6. Don’t forget that the Epilepsy Foundation of America has toll free help lines for assistance getting medication. Call your local EFA affiliate or the main office at 1 800 332-1000. The Web address is www.epilepsyfoundation.org.

Section Editor: Robert Fisher, M.D., Ph.D.
Submitted: November 25, 2008