Food Allergies and the Pharmacy

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Truth and Resolutions

Happy New Year!!

I want this year to be a year of transformation. I have resolved to be a healthier version of myself (focusing a bit more on me for a change–specifically health wise) and I have resolved to be a better advocate.

To be honest, I don’t like to write. I’m not a writer; heck I don’t even consider myself a blogger.

I like to research. I like discovery. I have a full time job working 12 hour shifts; I have two kids; I volunteer at a non-profit; I am a homeroom mom; I am a wife, a friend, a daughter, and a sister. And like everyone else reading this the chef, the maid, the chauffeur, the laundress…

I never intended to be an advocate; I had to worry about my son constantly as it was. Why blog about too. Or at least that’s what I thought, when I tried to talk myself OUT of doing this.

I began being “The Food Allergy Pharmacist” because I was horrified at some of what I was reading on various sites/groups regarding medications (in relation to allergies). I didn’t out myself as a pharmacist originally but as a person that can’t help but find solutions (or at least a path toward a solution) for any problem I find, I couldn’t sit by, doing nothing, knowing what actions/consequences may develop. Based on my years (and years–dang When did I get so old!?) of experience counseling patients and the lessons I have learned as a medical professional some information should be explicit, never implied, never assuming that what is obvious to one person is obvious to another. It’s not.

So my truth is that I’m not a good blogger. I don’t like to write BUT I am a good advocate in the sense that my information will be researched, reasoned, and factual. Mistakes will be dealt with promptly and openly.

Food Allergy Pharmacist resolutions include: 1. Post more often (I may even start having some of my students research and post as well)
2. Expand on the Teal Trunk or Treat Event I planned last Halloween (See I’m not a good blogger! I didn’t even post about that!) 3. Begin working with WV State Representatives to urge changes within WV law.
4. Get my CE (Continuing Education) program into full national realization. I already have a basic presentation finished (and have presented it at the local pharmacy school).

Happy New Year!

Please comment below with any suggestions for blog posts or if you have questions about the Teal (food free) Trunk or Treat.


Bottom of the Barrel

While traveling with E and A today, I visited one of Cracker Barrel‘s 600 locations.   E has never eaten at the Cracker Barrel but since so many restaurants have embraced the challenges of providing for allergic customers I thought I would give it a go. Welp…a half hour (and 3 bathroom breaks with a potty training 3 year old) later, we left with empty bellies, frustration, and PICTURES.

I will start with the positive. I appreciate the language added to the internal reference that specifies that the servers refer food allergy questions to a manager. I also appreciate the mention of cross contamination and the attention given to educate the server that even a small amount of a food allergen could be “life threatening” for some people.

Why did I italicize and bold internal?

Apparently, the Cracker Barrel feels that the customer should not be allowed to read its poorly developed and horribly executed allergy menu. The food allergen reference even specifies that “it should not be given to the guest or posted for public reference.”  Cracker Barrel even goes as far as to state that the server (or manager as it would seem) “must review ingredient labels and take extra care to prevent cross-contamination.”

I didn’t know any of this valuable information when I sat down. I didn’t know that I would have a server “suggesting” menu items to me off the “allergy menu” that I requested but was not allowed to read.

My waitress would not give me the menu, at first.

I simply explained that I deal with my son’s allergies every day and that there are several names for each allergen. I know these names. If you are reading this blog, you probably know them too. She, however, does not. And since I was not allowed to read the “menu,” I did not know how the information was listed or provided.  I convinced the waitress that I should be the one reading the menu.


Maybe Homa Woodrum could shed more light on this but I would assume that having the server/manager translate an allergy menu and specifically suggest food items would actually be more of a liability to the corporation.  This is even more poignant given the fact that the allergy menu specifically states that it should not be shown to the customer.

Another issue that gets me heated is their attempt to educate the waiter (who is then to educate the customer since the customers aren’t allowed to read the paper?) on the recommendation for the guest to “discuss with a physician” the need to avoid soy lecithin and soy oil.   Within the paperwork, I found a statement referencing the “Food Allergy and Anaphylaxis Network” which we know merged with the “Food Allergy Initiative” in 2012 to become FARE (Food Allergy Research and Education).  In the upper right hand corner of the menu the “revised” date of October 2013 can be seen.



So, not only was this menu updated with outdated information even at the time of its revision but also, it has not been addressed for a year and a half. Could it be possible that food venders, and potentially the food ingredients themselves, have changed over the course of a year and a half?  I think yes.

The FAAN statement talks about how soy lecithin and soy oil are not “indicated as allergens.” I guess this absolves the Cracker Barrel of the need to disclose these ingredients in the so-called allergy menu.  My son reacted to the type of soy oil to which most people do not react. I don’t need nor do I want lectured on soy from the waitress at the Cracker Barrel. I want ingredients. I want a clear, easy to understand menu that is updated frequently and does not talk down to me or belittle an allergen that is important in my family.

Needless to say, we did not eat there.  Additionally, I would not recommend any person with food allergies or sensitivities to consider Cracker Barrel unless some serious, extensive changes are made.  First and foremost, the customer should ALWAYS be allowed to read the ingredient list. Restaurants should be transparent with all aspects of food prep and content.  I am not talking about specific recipes of proprietary ingredients but simply the basic list of included food.  ALL food. Any and everything used in the making of the food. Period. Simple.

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Best Bang for Your Medication Bucks: Part 3

Part three of the series will focus on how the pharmacy can help you navigate and negotiate the best medication price and situation for you.



Some manufacturers/pharmacies have medications for one set price regardless of strength. Thirty of the 50 mg tablets may cost the same as thirty of the 100 mg tablet. This may be beneficial to you. Depending on the release mechanism, certain medications can be cut in half. Not all medications. Please do not just assume that a medication can be safely cut–always speak with your pharmacist first.

The pharmacist can process the scenarios to see which option would be the most beneficial. This may take a while. Ask the pharmacy staff to run the numbers and call you at a later time. You don’t want to rush him/her because options may be missed plus it’s just rude.  Please remember that the pharmacist may have several people asking for this service, in addition to doctor’s offices holding to give new prescriptions, vaccines to administer, interactions to call on, patients to counsel at pick up, a sick child’s medication waiting to be filled, the list goes on and on.

If you are using insurance, then this process becomes a bit more tricky. You will need to call the customer service number on the back of your card. Customer service will be able to provide you with a copy of your plan’s formulary (the list of medications covered and how much they cost). The formulary is the best way to evaluate medication coverage and cost when dealing with an insurance company. The plan formulary should be taken to each doctor appointment; this one step could save the doctor, the pharmacist, and ultimately you a lot of time and frustration (as in the case of prior authorizations, non-formulary and therefore higher priced meds, or medications that are just simply not covered at all).

Combination medications:

Some medications are offered singularly and also in combination; examples include lisinopril/hydrochlorothiazide, metformin/glyburide, and Janumet (Januvia/metformin). There are many reasons to take combination products such as ease of use, decreasing number of tablets taken per day, adherence (which is just a fancy word people in medicine use for saying that a person takes the medication every day as directed), and price.

Sometimes the price is a positive aspect of a combination product and sometimes it is a negative; for the purpose of this post I will only focus on price.

Knowing the right questions to ask will come in handy:

1. Do these individual medications come in a combination product?  Conversely, does this combination product come as individual medications?  If you have insurance, I would first look at the formulary for pricing, if not, ask the pharmacy staff to price out the individual medications and the combination.

2. Could I have a higher strength and cut it in half? What would be the cost?

3.  Is there another product in the same category of medication that costs less?  For example beta-blockers are a type of medication often used for blood pressure and heart rate control. There are several medications within this category: metoprolol, propranolol, nadolol, atenolol, etc. Additionally, metoprolol is found in an extended release version and an immediate release version. Extended release is more expensive but may only need to be taken once per day. Immediate release is less expensive and often taken multiple times per day. The choice becomes one of price vs convienence.

**Please take into consideration that not all medications within the same category will work for all people.  Even though medication A may be the least expensive, some patients may need Medication B for a variety of reasons including  effectiveness, side effects, lack of an appropriate choice for allergens, or drug interactions.  Your pharmacist and prescriber can weigh the pros and cons of one form or another and discuss which would be the most appropriate choice for your particular circumstance.

Why you should NOT Coupon Shop

First and foremost, in my opinion, hopping from pharmacy to pharmacy for $25 here and there is NOT SAFE. Large retail pharmacy chains often offer a cash incentive for transferring prescriptions but (and this is a huge BUT), pharmacists are unable to see your entire medication list when some are filled at Kroger, some at Rite Aid, and others at CVS, Walgreens, or the local independent. What this means is that interactions may and WILL be missed.

Another reason to find the pharmacy and pharmacist best for you and stick with him/her is due to allergy or intolerance issues. Pharmacy data bases are not currently equipped to handle these issues and the pharmacist must manually check the package inserts and potentially call the manufacturer to make sure that each medication is safe for the allergic patient.

Having a pharmacist that knows your special circumstances and goes above and beyond to ensure your or your child’s safety is invaluable.

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Best Bang for Your Medication Bucks : Part 2

Part two in the series will focus on discount cards, manufacturer coupons, and online sites for patient assistance.

Discount Cards:

Discount cards can be amazing things! However, please understand that by providing the pharmacy with those discount cards you are allowing this company (the discount card processor) to *possibly* have access to your personal information.  Research your cards carefully especially unsolicited cards delivered via USPS or email. Using a card affiliated with a national chain or a known non-profit organization is a safer option.

There seems to be a massive grey area with regards to discount card use.  Pharmacists at various chains have been told conflicting information about 1. whether pharmacies MUST accept the cards and 2. whether it is legal in certain circumstances to process the cards. And here is why…

1.  Unless there is a contract in place, pharmacies have no obligation to accept random discount cards especially if these cards cause the pharmacy to lose money. And yes, sometimes they do.  Each transaction comes with a processing fee (which is often how these companies make money) and sometimes the prices they set are below the actual cost for the pharmacy to purchase the medication from the wholesaler.   How can this happen?  I have no idea; but it does. I have personally seen a discount card give a price less than the pharmacy’s purchase price.

(Side note:  I wonder how much personal data the discount card processor obtains via these transactions; as a  chain retail pharmacist I am not privy to any of that information. I have tried researching it but ultimately came up empty handed. My advice is to use these cards with caution.)

2.  Some pharmacists/lawyers contend that discount cards legally cannot be used if you are enrolled in any plan that is supplemented by the federal or state government (Medicare, Medicaid, Tricare) due to the  federal anti-kickback statute. This means that even if you are paying the cash price because the insurance will not pay for the medication (or you are just choosing to not run the medication through the insurance) the discount card still cannot be used. Simply being enrolled in the program means that you are not allowed to use these offers.  Other entities interpret the law differently, stating that the discount cards may be used if the medication is 100% not covered by the state/federal program.

The bottom line is that each chain will determine its own policy based on the recommendations of that chain’s corporate attorney.  The answer to this question is something I have been struggling to track down for months; I hesitated to even post about it because the answers seem to be so variable but in the end, a discount card may be the best option in certain circumstances for people without insurance.

Keep in mind that pharmacies cannot legally bill your insurance then use a discount card on the copay.

Manufacturer Coupons:

Patients may obtain manufacturer coupons

1. Online. Sometimes you can apply for patient assistance online via a short questionairre on the medication or manufacturer’s official website. Use a search engine to inquire about the specific medication you need. Brand name medications will have their own website. Older medications may still have options for assistance through the manufacturer’s website. Simply do a search for the name of the medication and patient assistance or coupon.

2. By contacting the manufacturer directly (pharmacists can provide manufacturer phone numbers; I have also provided the contact information for epinephrine auto-injectors in my post)

3. From the pharmacist

4. From the prescriber

Again, just like the discount cards, patient’s enrolled in Medicare, Medicaid, or Tricare are typically not eligible but manufacturer coupons are a safe and legitimate way to obtain discounts.   Some manufacturers may even have patient assistance programs that surpass the individual discount card; it never hurts to call and ask.



Sites such as and have been mentioned in pharmacy publications and would be a good place to start. is also an approved e-advertiser for the NABP (National Association of Boards of Pharmacy) and has been featured in Forbes, Wall Street Journal, and the New York Times.












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Best Bang For Your Medication Bucks: Part 1

“How can I save money while still treating/controlling my medical issues?”

This is a question that every pharmacist has encountered and almost every patient has pondered. Cost is not everything, but if patients can’t afford the medication, they won’t buy it. Price is always a factor to consider.

As a pharmacist, I review medication profiles frequently and have been trained to quickly see where I could suggest changes to impact patient costs. In this three part series I will discuss several paths to medication savings.  Part 1 will focus on what the patients can do themselves to alleviate large medication costs. Part 2 will highlight the various discount card and patient assistance programs. Part 3 will concentrate on the pharmacist’s role in getting the best bang for your buck.

Today, I’ll be discussing the two major ways you, as the patient, can start saving immediately: discounted medication lists and price matching.

Discounted Medication Lists

Pharmacies such as Kroger, Wal-Mart, K-Mart,  Target, Rite-Aid, etc offer a large variety of medications on a discounted list. These medications are generally generics and are inexpensive for the pharmacies to purchase. The medications range from cholesterol and blood pressure medications to antidepressants and birth control.

Here’s what to keep in mind:

  • Pricing is not static.  A medication, a formulation such as tablets or capsules,  or just a specific strength can be removed from the list at any time. For instance, a recent national back order of Doxycycline caused this particular antibiotic to be pulled from these lists.
  • You will not be able to specify the manufacturer. These discounted prices are based on negotiations between a pharmacy and a specific manufacturer.  Therefore, while several pharmacies may list  30 capsules of generic Prozac, the generics will not all be provided from the same manufacturer. This may be a problem for allergy sufferers; as I discussed in a few of my “Pharmacy Basics” posts, different manufacturers may contain different inactive ingredients. Do your homework.

How can you best use this information?

My suggestion is that you print a few of these lists and take them to the doctor at your next appointment.  I have provided links to several national chains at the end of this post.  The prescriber can then evaluate if any of the cost saving options are appropriate. The pharmacy, however, will help you with the specific selections and potential allergens.   

Bear in mind that the trade-off for best pricing is often convenience. Making the decision to go with the best priced medication may mean taking more tablets and/or taking the tablets more frequently.  This is a serious issue to consider. The medication won’t help if you don’t remember to take it.

Once the doctor prescribes the medication, you can go to the pharmacy with the best price or you can utilize the next tip.

Price Matching

Large retail pharmacies often price match within their immediate area (which does not include pharmacies three hours away or mail order, unfortunately).  The price match is matching the “cash” price or the price of the medication without any insurance or discount cards.

Pharmacies typically require confirmation of the price/quantity/strength/NDC;  this will need to happen often (if not every time), per corporate policy,  if the price match continues. Medication costs change frequently and therefore the pharmacy’s cost to purchase medications changes as well. Some pharmacies even match the “club” prices of competing chains without the patient actually having to shell out the “club” membership dues or prove membership.

But, as the Genie, said, “There are a few, uh, provisos. Ah, a couple of quid pro quo.”

  • Not all medications are subject to price matching; some retail stores exclude controlled substances from price matching, others allow the pharmacist to use professional discretion.
  • While most insurance plans have a standard copay for the medication regardless of which pharmacy you use, some companies  mandate the use of specific retail pharmacies or mail order pharmacies in order to get the best pricing. These details will be listed in the informational packets provided by your insurance company.
  • Percentage Based Copays

If you have copays based on a percentage of the cash price; price matching will not work.  You must have your medication filled at the least expensive location to get the best pricing. There is no way for the local pharmacy   staff to match a cash price and bill the insurance for the cheaper price–the pharmacy computer system will not allow it.  So in these percentage based copay plans, the best bang for your buck is at the cheapest pharmacy–the pharmacy with the least expensive cash price.

This type of copay system is problematic in that it encourages pharmacy hopping (when a patient goes from pharmacy to pharmacy instead of sticking with one location); in my opinion, this is a patient safety hazard and can be downright dangerous.  I will discuss this more in Part 3. Once you find a pharmacist that understands your unique needs as a food allergic individual, my advice is that you stay put (if at all possible). Educating pharmacists and pharmacy techs about the food allergens in medications is a work in progress. Locating a heath care professional that “gets it” is priceless.

As always, please comment with specific questions or further resources. Stay tuned for Parts 2 and 3, coming soon!




Sam’s Club:








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Influenza Vaccine Chart 2014-2015

Much thanks to Andrea Brookhart, PharmD and her colleagues, pharmacy residents MacKenzie VonCanon, PharmD and Hannah Kuhn, PharmD for allowing me to use their awesome chart! There is also a link to a printable version at the bottom of the page.  These are the vaccines that will be found at most local retail pharmacy locations.

I have provided information on Flucelvax and Flublok below the chart.




  • 100% egg free
  • Indicated for people 18 or older
  • Most common adverse reactions include: pain at injection site, headache, fatigue, and muscle pain
  • Does not contain any preservatives, gelatin, thimerosal (mercury derivative), antibiotics, or formaldehyde
  • Trivalent (covers three strains of influenza virus)
  • Latex free
  • Pregnancy Category B; not evaluated in nursing mothers
  • Safety and efficacy in pregnancy has not been established per package insert (even though it is listed as a pregnancy category B). Pregnant women who receive Flublok are to be registered in the Flublok pregnancy registry.
  • Warnings: Guillain-Barre syndrome w/in 6 weeks of previous vaccine
  • According to the website, Flublok is not available in all states (based on health provider ordering practices). Use this link to (hopefully) find a site close to you.
  • All information taken from the Flublok package insert



  • Indicated for people 18 or older
  • Tip caps of pre-filled syringes contain latex
  • Most common adverse reactions include: pain at injection site, headache, fatigue, and muscle pain
  • Does not contain preservatives or antibiotics
  • Trivalent (covers three strains of the influenza virus)
  • Virus is propagated in Madin Darby Canine Kidney cells (MDCK). For more information on how this works see my post Influenza Questions Answered
  • Warnings:  Guillain-Barre syndrome w/in 6 weeks of previous vaccine
  • Pregnancy Category B; not evaluated in nursing mothers
  • Flucelvax can be found only in select retail locations. Use this link to find a location near you.
  • All information taken from the Flucelvax package insert


Printable PDF:   Influenza Vaccine Chart 2014-2015