How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?

This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record.

Your question begs another question, however. Specialty practices are often filled, making access difficult. If patients are stable in their treatment and require only quarterly visits, I refer them back to primary care for follow-up. I have a deal with the local primary care providers that I remain available to them for further consultation whenever needed. This fluid treatment team provides both continuity of care for kids and ready access.

My practice is all adults, yet I have a fair number of patients who are taking controlled medications. In the case of stimulants, I will proactively send three 30-day prescriptions, one for each of the next three months, and then see the patient(s) quarterly. I have had no issues with local pharmacies objecting to my "post-dating" those prescriptions.

The DEA allows up to 90 days for a C-II drug to be prescribed on any given day (this applies mostly to stimulants and not opioids, which have other restrictions). It can be prescribed all at once or in smaller increments like 30, 45, or 60 days, etc. with a current date. If for a future month, an additional "may fill on" date is required, again, up to 90 days of supply is permissible to prescribe on any one day.

Before the prior Rx(s) are completed, a new one can be written for up to another 90 days. There does NOT seem to be a requirement that the patient have a check-in visit every 90 days. It is only necessary that the physician prescribe according to good medical practices.

If very stable patients do not need to be seen every three mont...

I always see patients monthly in the beginning to make sure they are stable. After a few months, I’ll go every other then every 3 months. I’ll bring them in if we need to change something before the 3 months, and I am available to patients to meet sooner if needed for other reasons. I’m pretty strict on the 90-day rule.

1. Yes, absolutely. To my knowledge, the only thing that is relevant is the doctor-patient relationship.
2. Insurance companies' 30-day imposition is not based on care, compassionate medicine, nor science or evidence-based beyond shaping clinician behavior.
3. See 1 above. The 30-day limit appeared de novo around the late 1990s. I called the DEA and the Texas DPS board at the time to further inform myself. As I recall, I was informed there is no limit other than responsible care.

See your patient. Know your patient. Initially or with medication adjustments, space one’s visits. With stability, I was taught to proceed from weekly (evaluating a new patient on new meds in an outpatient and stable setting) to monthly, then every 2 months in the first y...

Addendum: I just saw 'part 2' of the question, would I consider charging a small fee for refills in between visits? Yes, I am seriously considering doing so. This is because refilling stimulants, with the never-ending supply chain shortage, insurance denials, and extra time required for controlled Rx renewals is, cumulatively, a major time requirement in my solo practice. I am seriously contemplating charging a $10 controlled medicine renewal fee. I would ask the patient to include, along with the refill request, an update as to how they are doing and how they are managing their symptoms. If I decide to impose the fee, I'll point out to the patient that the $10 fee and clinical update via text or email, represent a time and cost-savings to ...

I think it is important to see adult patients on stimulants at least every 3 months to monitor blood pressure, which can creep up in patients over time even when the dose remains the same and other factors are stable - you won't see it unless you are monitoring for it! This could be done in a nurse/MA visit if the patient is otherwise stable.

I now have a small practice (past retirement age!) and have 5 patients on stimulants. I see them all at least monthly by their choice. But when I worked in a large health care system, I saw everyone every 90 days, and that felt right. It gave me a chance to assess the efficacy of the meds.