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STATE BOARD
OF PHARMACY

Long-Term Care Forms

[39 Pa.B. 1377]
[Saturday, March 14, 2009]

   The State Board of Pharmacy (Board) has developed the forms required by section 5(b)(3) and (4) of the Long-Term Care Patient Access to Pharmaceuticals Act (P. L. ____ , No. 114). The Prescriber Consent Form and the Authorization to Admister Repackaged and Relabeled Medications form may be downloaded from the Boards' web site at www.dos.state.pa.us/pharm.

MICHAEL A. PODGURSKI, R.Ph.,   
Chairperson

Prescriber Consent Form

   The Long-Term Care Patient Access to Pharmaceuticals Act, (P. L. ____ , No. 114) allows eligible patients in long-term care facilities to acquire lower cost drugs through the Veterans' Administration. The pharmacy within the long-term care facility or that has a contract with the long-term care facility may receive the lower cost drugs directly from the Veterans' Administration drug benefit program in the patient's name and repackage and relabel those drugs so they may be dispensed in unit doses in compliance with the Food and Drug Administration, the United States Pharmacopeia and the long-term care facility's policies and procedures to eligible patients in a long-term care facility.

   I hereby authorize ______ , a long-term care facility, to administer medications prescribed by me, for patient, ______ , whose medications are provided by a drug source facility approved by, operated by, or operated under contract with the Veterans' Administration, and are repackaged, relabeled and dispensed in unit doses by the pharmacist employed by the long-term care facility or by a pharmacy who contracts with the long-term care facility to fill prescriptions for patients of the long-term care facility.

Prescriber's signature: __________

Prescriber's Printed name: __________

Date: ______

Authorization to Administer Repackaged and Relabeled Medications

   The Long-Term Care Patient Access to Pharmaceuticals Act, (P. L. ____ , No. 114) allows eligible patients in long-term care facilities to acquire lower cost drugs through the Veterans' Administration. The pharmacy within the long-term care facility or that has a contract with the long-term care facility (hereinafter referred to as ''pharmacy'') may receive the lower cost drugs directly from the Veterans' Administration drug benefit program in the patient's name and repackage and relabel those drugs so they may be dispensed in unit doses in compliance with the Food and Drug Administration, the United States Pharmacopeia and the long-term care facility's policies and procedures to patients in a long-term care facility.

   I acknowledge that I am aware that the pharmacy is required to go through the process of repackaging and relabeling the drug. The pharmacy may charge a fee for repackaging and relabeling the drug of no more than the maximum dispensing fee authorized by the Department of Public Welfare regulations under the Medical Assistance Program. The amount the pharmacy charges for repackaging and relabeling a drug into unit doses is ______ and the frequency of its assessment is ______ .

   The pharmacy has the following immunities from civil liability arising from dispensation of the drug if the pharmacy properly repackages and relabels the drug as set forth in the Long-Term Care Patient Access to Pharmaceuticals Act:

   Repackaging and relabeling.--A person authorized under section 5(a) of the Long-Term Care Patient Access to Pharmaceuticals Act to dispense a drug shall be immune from civil liability arising out of dispensation of the drug if the person properly repackages and relabels a drug based on the information received from the original drug source facility.

   Administration of drug.--A long-term care facility or an employee or agent of a long-term care facility that properly administers a drug from a person authorized under section 5(a) of the Long-Term Care Patient Access to Pharmaceuticals Act to dispense the drug shall be immune from civil liability arising out of administration of the drug.

   Unprofessional conduct.--A pharmacist authorized under section 5(a) of the Long-Term Care Patient Access to Pharmaceuticals Act to dispense a drug who properly relabels and repackages the drug shall not be deemed to have engaged in unprofessional conduct under section 5 of the Pharmacy Act, 63 P. S. § 390-5.

   By signing this form I am authorizing ______ , a long-term care facility, providing services to patient, ______ , to administer a drug from a drug source facility approved by, operated by, or operated under contract with the Veterans' Administration that has been repackaged and relabeled by the pharmacy.

Signature: __________

Printed name: __________

[  ] Patient[  ] Parent/Guardian
[  ] Power of Attorney [  ] Authorized family member

Date: ______

[Pa.B. Doc. No. 09-509. Filed for public inspection March 13, 2009, 9:00 a.m.]

 

[39 Pa.B. 1379]
[Saturday, March 14, 2009]

 

 



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