Alex dropped his briefcase and the prescription bag he’d just picked up from the drugstore on the kitchen table. “Honey?” he called out. “I’m home.”

A couple of hours later, after dinner and the flurry of activity that having teenagers entailed, Alex ripped the bag open, twisted off the cap on the prescription bottle, and had a pill six inches from his mouth when he really looked at it for the first time.

It was orange. The pills he was used to taking were white.

Confused, he paused for a moment and stared at the pill. It was still orange. Curious, he looked at the bottle. He still didn’t understand. He started reading – and found that the bottle had someone else’s name on it. And someone else’s medicine in it.

He called the pharmacy, feeling betrayed. They quickly replaced the bottle, apologizing profusely for the inconvenience.

Alex was shaken by the experience. He had thought that pharmacies were like ATM machines. How often do you hear of people being given the wrong amount of money by an ATM? Never. How often did he expect to be given the wrong medicine by a pharmacy? Never.

A few months later, Alex had to refill another prescription. Having been given the wrong pills once before, he was now cautious when he brought refills home from the drug store. He opened the bag and took the bottle out. These pills were a different color from the ones he’d been taking, and they were bigger, too. He couldn’t believe that the pharmacy had made another mistake.

He called the store and got the pharmacist on the line. After answering the pharmacist’s questions about the pills’ shape, color, and markings, the pharmacist said, “You did the right thing to check, but those are the right pills, in a 10 mg dose.”

“Ten milligrams?” Alex said. “But I’m only supposed to be taking 5 mg. These aren’t the right pills at all!”

“You’re right that your prescription is for 5 mg, but your insurance company’s rules say that you get 10 mg pills and split them, and take half a pill at a time. See the scoring on the pills? They’re pretty easy to split in half. You can do it with a knife, although it’s safer to do it with a pill splitter. We sell them here; they’re inexpensive.”

Alex was so surprised that he was sputtering. “You gave me pills that I have to split in half? How was I supposed to know that? Every time I’ve gotten this prescription filled in the past, I’ve been given 5 mg pills. If I had just taken one pill a day as I always have, I would have been taking twice as much as I was prescribed! Who was supposed to explain this change to me?”

Alex could almost hear the pharmacist shrug over the phone. “Your insurance company makes the rules. It’s less expensive and just as effective to take larger pills and split them as it is to take smaller pills. So that’s their policy. We have to follow their rules.”

Alex asked, “Does my doctor know about this?”

“Don’t know,” said the pharmacist. “You’d have to ask him.”

Both of Alex’s experiences highlight the need to be very careful when you get a new prescription or even a refill of a prescription you’ve had for a long time.

Steps you can take to protect yourself include:

  1. Make sure that the label has your name on it.  
  2. Confirm that the name of the medicine is what you were expecting. If the label doesn’t give the brand name and you’re unfamiliar with the generic name, look it up online or call the pharmacy to check that it’s the drug you were expecting.  
  3. Check that the drug dosage is what you expected. 
  4. If the pills in a refill look different from the pills you’ve had before, go to to verify that you’ve been given the right drug. The site offers a Pill Identifier function. After you enter the pill’s color, shape, and markings, the program will tell you what drug it contains.