Medication Synchronization
MedSyncWorksheet
Patient: __________________________________________________ D.O.B. ______ /______ /_________ First Synchronized Fill On _______ /_______ /___________
Pharmacist: ______________________________________________ MedSync Plan Created On _______ /_______ /___________
Medication
Fill
QTY
Days
Supply
Last
Filled
Earliest
Refill Date
Refill
Due By
Common
Fill Date
Date for
Short Fill
QTY
Date for Next
Full Fill
QTY
EXAMPLE ONLY - Lisinopril 30 30 1/1/2016 1/26/2016 1/31/2016 2/14/2016 1/30/2016 15 2/14/2016 30
EXAMPLE ONLY - Atorvastatin 30 30 1/15/2016 2/8/2016 2/14/2016 2/14/2016 - - 2/14/2016 30
Glossary:
Earliest Refill Date: Typically 80% of the
current days supply
Common Fill Date: Date you selected to fill
all chronic medications together; also known
as the medication synchronization date
Enter included medications Create the synchronization plan
1
2
3
4
5
6
7
8
9
10
Notes:
> Do not include unit-of-use items (ointments,
eye drops, etc.) or as needed (PRN) medications.
> Choose a common fill date that will maximize
the number of full Rx fills.
> The earliest fill date varies by health plan. Check the
Refill Too Soon date to see if your planned fill is allowed.
> Use Submission Clarification Codes when needed. When
the prescription is filled for less than a 30-day supply, use 47.
For subsequent fills, use 48 to override Refill Too Soon.
[Pharmacy use only]
