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Pharmacist FAQs

Frequently Asked Questions for Pharmacists on Transferring Prescriptions

 

Q: What are a pharmacy's responsibilities when a patient requests a transfer?

A: On a semi-regular basis, Board staff receive calls from pharmacists raising concerns or complaints about prescription transfer practices.  Typically, the concern or complaint takes one of the following forms:  (a) the pharmacist complains that another pharmacy (or, more frequently, a particular pharmacist) refuses to transfer prescriptions upon request; (b) the pharmacist complains that another pharmacy (or pharmacist) agrees to transfer prescriptions, but takes a long time to do so; (c) the pharmacist complains that another pharmacy (or pharmacist) is “tricking” or “coercing” patients into transferring prescriptions. 

Let’s set the table.  Board of Pharmacy Rule .1806 (21 NCAC 46.1806) authorizes the transfer of prescriptions among pharmacies, and it sets forth procedural and recordkeeping requirements for doing so.  Pharmacists seldom have questions about these procedural or recordkeeping requirements.  Instead, most of the focus in these situations is one word in the rule – “permissible.”  The introductory language of Rule .1806 says that the “transfer of original prescription information for the purpose of refill dispensing is permissible between pharmacies . . . .”  Pharmacies or pharmacists who have refused to transfer a prescription typically respond to a complaint by saying that the rule makes transfers “permissible,” and not “mandatory.”  What tends to get lost in this blinkered argument is the most important factor – the patient.

Patients have the right to select their pharmacy provider.  Patients have many reasons for choosing a particular pharmacy in the first instance, or deciding that they wish to change to a different pharmacy.  Whatever those reasons, the patient is the decision maker.  A patient’s wishes must be respected not only because it’s the right thing to do, but also to avoid interruption of care that could well prove harmful to the patient. 

With this background in mind, this is how Board staff approach transfer complaints:

  1.  Pharmacists are expected to consult with one another professionally and politely to resolve transfer issues.  Staff often find that the root of a transfer dispute is a personal or business conflict among pharmacists or pharmacies.  These sorts of disputes are not a reason to involve the Board, nor are they a reason to delay (or deny) a patient’s care. 
  2. In some cases, a pharmacist alleged to have wrongly refused a transfer will state that he/she simply wants to confirm the request with the patient.  That, in and of itself, doesn’t necessarily raise an issue.  But “I’m checking with the patient” must not become a pretext for denying a transfer or delaying one to such a degree that the patient’s continuity of care is jeopardized.   And pharmacy policies and procedures that incentivize staff pharmacists to delay or deny transfers place those pharmacists, the pharmacist-manager, and the pharmacy permit in potential jeopardy.
  3. Board staff treats a transfer complaint from a patient as a higher priority matter than a transfer complaint from a pharmacist.  This is because, as noted above, transfer complaints relayed by pharmacists are often rooted in personal or business conflicts.  Direct patient complaints are more typically rooted in potential harm resulting from interrupted drug therapy.  A patient who alerts the Board that his/her transfer request is not being honored, or is not being honored in a timely fashion, will find a ready ear and a helping hand from Board staff. 
  4. If, after a patient complaint, neither professional consultation among the pharmacists nor informal intervention of Board staff (usually by way of a phone call to both pharmacists with a suggestion that the patient’s request be met without further delay), Board staff will open a case and pursue it as a disciplinary matter focusing on potential negligence in a pharmacist’s/pharmacy’s outright refusal to transfer or a dilatory transfer.
  5. Pharmacies are expected to have adequate staff on hand to fulfill a patient’s transfer request in a timely fashion.   As noted in Item 2389 of the July 2019 Newsletter (http://www.ncbop.org/Newsletters/July2019.pdf), in recent months some pharmacies have abruptly closed without adequate (and legally required) notice to patients.  Predictably, this results in the pharmacy receiving the prescription files getting bombarded with transfer requests.  The pharmacist-manager of the receiving pharmacy must staff it sufficiently to accomplish timely transfers.  Failure to do so will lead to a Board staff investigation and potential discipline.
  6. If a pharmacy or pharmacist complains to the Board that it believes a patient was “tricked” or “coerced” into transferring prescriptions, Board staff needs, at a minimum, the patient’s name and contact information and strongly prefers to receive the complaint from the patient directly.  In Board staff’s experience, most often the patient explains that he/she did authorize a transfer but was uncomfortable admitting this to his/her now-former pharmacy.  But if a patient directly alleges that he/she experienced a transfer that he/she did not authorize, that is a serious matter that could involve not only the Board of Pharmacy, but also law enforcement agencies or the North Carolina Attorney General’s office.

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Q:  May a pharmacy transfer an “on file” prescription for a controlled substance that the pharmacy never dispensed?

A:  Pharmacists continue to call Board staff with understandable confusion on whether and how “on file” controlled substance prescriptions that were never filled may be transferred.

In April 2017, word began swirling that DEA viewed transfers of “on file” controlled substances as not allowed.  On July 7, 2017, Loren Miller, Associate Section Chief, Liaison and Policy Section, Diversion Control Division, Drug Enforcement Administration sent an email to Carmen Catizone, Executive Director of the National Association of Boards of Pharmacy, setting forth DEA’s view on the matter.

In that email (found here --  http://www.ncbop.org/PDF/LMillerDEAGuidanceTransferofOnFileCSPrescriptions.pdf), Mr. Miller states the view that 21 CFR 1306.25 allows a pharmacy, “once it has filled an original prescription for a controlled substance in Schedule III-V,” to “transfer the original prescription information to another DEA registered pharmacy for the purposes of allowing that second pharmacy to then dispense any remaining valid refills . . . .”  Mr. Miller further stated that “an allowance currently does not exist for the forwarding of an unfilled prescription from one DEA registered retail pharmacy so that it may be filled at another DEA registered pharmacy.”

Mr. Miller then stated that, based on “the preamble” of an “interim final rule,” it is DEA’s “policy” that an electronic prescription for a controlled substance of any schedule may be “forwarded from one DEA registered retail pharmacy to another DEA registered retail pharmacy” even if that prescription had not been filled.

To say that DEA’s positions in this matter create a mess is a gross understatement.  First, while Mr. Miller’s reading of 21 CFR 1306.25 is textually plausible, it represents a departure from decades of standard pharmacy practice and there has been no suggestion from DEA or anyone else that the standard practice of transferring “on file” but unfilled (as opposed to once-filled) controlled substance prescriptions has caused or materially contributed to controlled substance abuse or misuse.  Second, neither Mr. Miller’s email nor any language in the preamble he references contains so much as a hint as to what an appropriate mechanism for “forwarding” (and documenting the forwarding of) an unfilled electronic controlled substance prescription would be.  Third, Mr. Miller’s email does not explain why “forwarding” an unfilled electronic controlled substance prescription is substantively different than transferring an unfilled controlled substance prescription, whether electronic, verbal, or written.  Fourth, DEA’s position creates not only an incentive, but a practical necessity, for patients  seeking to change their pharmacy of choice to obtain duplicate controlled substance prescriptions from their caregiver.  Interpretations and policies that guarantee duplicate prescriptions for controlled substances in multiple pharmacies hardly seems consistent with the Controlled Substance Act’s purpose to create a controlled, closed distribution system and minimize controlled substance abuse and misuse.

All that said, however, DEA has shown no inclination to reconsider or clarify these positions.  Where does that leave us?

(1)  Though “forwarding” of unfilled electronic controlled substance prescriptions is available by “policy,” the lack of any guidance from DEA on how a “forwarding” should occur and be documented means that most pharmacies and pharmacists are reluctant to entertain the practice.  And who can blame them?

(2)  For unfilled verbal prescriptions for a Schedule III-V controlled substances, DEA’s position means that there is no mechanism for moving them from one pharmacy to another.

(3)  For unfilled paper prescriptions for a Schedule III-V controlled substances, a pharmacy could return the original to the patient to physically carry to another pharmacy.  Board staff understand completely the practical problems of this approach.

Some pharmacists have inquired why Board staff, the Board, or the North Carolina legislature have taken this position.  As the above makes clear, none of the three are to blame.  The present state of affairs is attributable solely, and entirely, to the DEA.  Board staff will, of course, update pharmacists if the DEA sees reason and backs away from these positions.  Until then, send your cards, letters, and calls to the DEA. 

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Q: May a pharmacy transfer prescription drugs to another pharmacy?

A: North Carolina Wholesale Prescription Drug Distributors Laws provide (N.C.G.S. 106-145.2(10)(e)): "The sale, purchase, or trade of a prescription drug or an offer to sell, purchase or trade a prescription drug for emergency medical reasons. Emergency medical reasons include transfers of prescription drugs by a retail pharmacy to another retail pharmacy to alleviate a temporary shortage when the gross dollar value of the transfer does not exceed 5% of the total prescription drug sales revenue of either the transferor or transferee pharmacy during a 12 consecutive month period."

Transfers between pharmacies that fall outside these guidelines would require a North Carolina wholesaler license. Note that the simple sale of excess stock to another pharmacy would be a wholesale activity. Pharmacists should also be aware that federal pedigree requirements could bear on transfers. And transfer of controlled substances between pharmacies requires compliance with all pertinent provisions of the federal Controlled Substances Act and associated regulations.

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Q: May a technician, certified technician, or pharmacy student transfer or receive transfers of prescriptions for controlled substances?

A: Under federal law, an original prescription for a C-III, C-IV, or C-V substance may be transferred for refill on a one-time basis. If pharmacies electronically share a “real-time, on-line database,” then those sharing pharmacies “may transfer up to the maximum refills permitted by law and the prescriber’s authorization.” 21 C.F.R. § 1306.25(a).

Federal law, however, requires that any transfer of a C-III, C-IV, or C-V prescription be “communicated directly between two licensed pharmacists . . . .” 21 C.F.R. § 1306.25(a)(1).

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Q: Can prescriptions be transferred more than once in North Carolina?

A: Yes, provided that refill authorizations still exist and there are restrictions on controlled substances. Prescriptions for non-controlled drugs can be transferred from one store to another indefinitely providing that refill authorizations do exist.

Federal rules (1306.25(a)) permit multiple transfers of controlled substances, provided that authorization exists, only for those pharmacies that share a real time on-line electronic database. Other pharmacies are limited to one transfer only under federal rules.

 

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