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Q: A client asked me to write a prescription rather than dispense a prescription drug out of my clinic. What are my rights and responsibilities?
A:
The AVMA developed a position statement to guide your actions. The AVMA encourages veterinarians to honor client requests to prescribe rather than dispense a drug when a veterinarian-client-patient relationship exists and the veterinarian has determined that the drug is medically necessary. If the veterinarian does not have a veterinarian-client-patient relationship or does not believe the drug is medically indicated, the veterinarian should not write the prescription.
If the veterinarian has determined that dispensing the drug from the clinic may be best for the patient or client, the veterinarian may wish to explain the reasons for this to the client. If, however, the client prefers a prescription to a dispensed drug, veterinarians should honor client requests to prescribe rather than dispense a drug. The client has the option of filling a prescription at any pharmacy.
Some state regulations require a veterinarian to provide a prescription rather than dispense a drug when requested by the client. None of these laws require the veterinarian to write a prescription in the absence of a veterinarian-client-patient relationship or if the drug is not medically indicated. Veterinarians should ascertain state requirements by contacting the Board of Veterinary Medicine in the state(s) in which they are licensed. Also, depending upon the state, Board of Pharmacy regulations may also apply to veterinarians as handlers of prescription drugs. Therefore, veterinarians should make themselves aware of any pertinent Board of Pharmacy regulations in their state. State veterinary medical associations work on your behalf to monitor state issues that affect veterinary medicine and may be a very helpful resource.
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Q: My client has found a pharmacy on the Internet, but it is located outside our state. Must I be licensed in the state of the pharmacy to authorize a prescription?
A:
No. The client has the option of filling a prescription at any authorized pharmacy. In this example, the veterinarian's practice of veterinary medicine, which would include writing a prescription, would be confined to his/her state.
Dispensing a drug on the valid prescription of a professional is the practice of pharmacy. An Internet pharmacy may be authorized to fill prescriptions in a state in which it is not physically located if it has registered as an "out of state" pharmacy and agrees to meet the standards of the states to which drugs are shipped.
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Q: Am I obligated to authorize a phoned or faxed prescription request from a pharmacy?
A:
Veterinarians asked by pharmacies to approve prescriptions should do so only if the prescription is medically appropriate for that patient and a valid veterinarian-client-patient relationship exists. The veterinarian may prefer to issue a written prescription in order to leave the responsibility of choosing a pharmacy to the client. The decision as to whether a prescription drug should be used for a patient is made by a veterinarian, not a pharmacy.
It is atypical and generally inappropriate for any pharmacy to call and "initiate" a prescription for a new drug not previously prescribed. It may be acceptable in some states for registered pharmacists to call or fax to obtain refills on existing medications. Check with your state Board of Pharmacy for its specific regulations.
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Q: May I charge for authorizing a prescription?
A:
The structuring of fees is an individual business decision. The AVMA does not have a position on this subject. Check with your state Board of Veterinary Medicine to determine if it has any regulations or policies on this subject. State veterinary medical associations are another good source of information on pertinent regulations in your state that might influence this decision.
In general, veterinarians must charge adequately for their professional services to cover the costs of maintaining a veterinary clinic, paying staff, and offering quality medical care to client's animals. Some have chosen to charge a prescription issuance fee in those cases when the veterinarian does not directly dispense the medication to the client. Others have expressed some concern that this could be regarded as discriminatory, in that effectively clients would be charged different prices for the same product depending upon whether it is dispensed within or outside the clinic. Some have considered implementing a policy to charge a specified fee, whether a drug is dispensed or prescribed. Others have reviewed fees and the need for any adjustments within the context of all services rendered. Others charge for their professional services using units of time (e.g. when reviewing prescription drug authorizations or conducting telephone consultations with clients). Because state laws differ with regard to the legality of commissions on referred sales of veterinary prescription products, veterinarians should confer with an attorney prior to entering such arrangements. Check with your state Board of Pharmacy and Board of Veterinary Medicine for regulation on the subject. Practice management consultants may be helpful resources.
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Q: How can clients identify a quality Internet pharmacy?
A:
The National Association of Boards of Pharmacy has created a voluntary pharmacy certification program called Vet-VIPPS (Verified Internet Pharmacy Practice Sites) to help consumers evaluate Internet pharmacies. The Vet-VIPPS seal of approval identifies those online pharmacies that, according to NABP, are appropriately licensed and prepared to practice pharmacy via the Internet. Clients should be encouraged to report any problems encountered with an Internet pharmacy to the state Board of Pharmacy in the state from which the products were shipped and the state to which the products were shipped.
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Q: Sometimes I run low on a prescription drug and it would be helpful to send the client to another practice for the drug. Can another veterinarian dispense a prescription drug to my client on the basis of my authorization?
A:
Perhaps not; make certain you check the regulations of your state Board of Veterinary Medicine and your Board of Pharmacy. Your State Veterinary Medical Association may be another good resource for this state-specific issue.
If the second veterinarian dispenses the drug, but does not have a veterinarian-client-patient relationship nor keep medical records for the patient, he/she may be judged to be acting as a pharmacist outside the scope of veterinary medicine. Some states have regulations that prohibit the veterinarian from filling another veterinarian's prescription, asserting that one would have to be a registered pharmacist to conduct such activity. Perhaps the veterinarian can borrow the drug from another practice and dispense it to the client. Check with your state Board of Pharmacy to see if this is legal in your state.
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Q: How do I determine if a pharmacy has complied with regulations designed to protect the public? Might failure to comply with state and federal prescription drug laws place clients and their animals at risk?
A:
No veterinarian can ensure compliance and you are not obligated to do so, though it is understandable that you would wish the best for your patient and client. Reporting irregularities will alert regulators to potential problems. Just as your license is subject to review by the state Board of Veterinary Medicine, a pharmacist's registration is subject to review by the state Board of Pharmacy.
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Q: I believe an Internet pharmacy has performed an illegal act (for example, dispensing a prescription drug to my client without my authorization as the attending veterinarian who has a veterinarian-client-patient relationship). What should I do?
A:
Report it! The AVMA has created a Prescribing and Dispensing Complaint Form (PDF) to simplify the reporting process for practitioners. The form identifies the organizations to which the form should be sent. Regulatory agencies cannot act unless they have factual complaints to pursue.
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Q: My client tells me that an Internet pharmacy has offered to have its "pharmacy staff veterinarian" (who resides outside of my state) authorize the prescription without requiring my authorization as the attending veterinarian. Is this legal?
A:
No! Report it! As you are aware, in order to be in compliance with the state practice acts, veterinarians must have a veterinarian-client-patient relationship (VCPR) before prescribing prescription drugs. The AVMA believes that a VCPR cannot be created over the telephone. The same is true for the pharmacist; in order to be in compliance with Board of Pharmacy regulations, pharmacists must possess a valid prescription before dispensing drugs. The FDA can also take action if prescription drugs are sold without a valid prescription. Therefore, the AVMA encourages veterinarians to report such observations to the proper authorities by completing the Prescribing and Dispensing Complaint Form (PDF).
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Q: I've heard that some Internet pharmacies are challenging the practices of the attending veterinarian through means that appear to include intimidation of the practitioner and the creation of adversarial relationships between clients and their veterinarians. How is this being done?
A:
Areas of challenge include frequency of heartworm testing, charging for prescriptions, and failure to provide a prescription.
Veterinarians can best explain their policies if they are familiar with heartworm testing guidelines, including those of the American Heartworm Society; they have considered the pros and cons of charging specifically for issuing a prescription, including checking with state authorities on this practice; and have grounded the refusal of any written prescriptions on the basis of medical reasons.
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Q: What should I do if an Internet pharmacy reports me to my state veterinary board or the Federal Trade Commission for refusing to authorize a prescription?
A:
Veterinarians should report perceived threats and/or intimidations to state and federal agencies using the Prescribing and Dispensing Complaint Form (PDF).
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Q: What kinds of rogue activity should I be aware of? What concerns have my colleagues reported?
A:
"Rogue activities" are practices of some pharmacies that appear to be contrary to FDA and other regulation and inconsistent with best patient care.
The AVMA has received the following sampling of concerns from veterinarians:
- Pharmacy dispensed prescription drugs in the absence of a valid authorization, i.e. without the consent of the attending veterinarian
- Pharmacy indicated it received veterinarian prescription authorization despite animal hospital evidence to the contrary
- Pharmacy dispensed prescription drugs despite the specific rejection of authorization by the veterinarian for medical reasons
- Pharmacy dispensed prescription drugs bearing the name of a "pharmacy staff veterinarian" despite the lack of a veterinarian-client-patient relationship
- Pharmacy dispensed prescription heartworm medication to heartworm positive dog
- Pharmacy dispensed prescription drugs with packaging that had been stripped of distribution tracking bar coding
- Pharmacy dispensed prescription drugs bearing the name of the attending veterinarian without his/her authorization
- Pharmacy dispensed prescription drugs without authorization of the attending veterinarian and without the consumer's consent to purchase
- Pharmacy company materials state the desire to dispense prescription drugs to animal owners without the involvement of the attending veterinarian
- Pharmacy dispensed unauthorized prescription drug to animal owner, duplicating what had been purchased from attending veterinarian
- Pharmacy advertising promotes the provision of prescription drugs for animals without need to go to a veterinarian
- Pharmacy requested authorization for prescription drug quantities that exceeded the amount that would be used in one year (as much as a 4 year supply)
- Pharmacy altered the number of refills following authorization of prescription drugs
- Pharmacy dispensed prescription drugs bearing packaging other than that of U.S. FDA approved drugs (i.e., foreign drugs)
- Pharmacy dispensed pesticides bearing packaging other than that of U.S. EPA registered pesticides
- Pharmacy drove prescription requests by "cold calling" animal owners and offering to dispense medications
If you have observed any of these situations or others that are similar, DO NOT assume that your concern is taken care of. Do not be complacent. Report your observations to the proper regulators! Use the Prescribing and Dispensing Complaint Form (PDF). Regulatory agencies face competing priorities and limited resources. Add to the number of complaints and make these issues a priority! The AVMA has no regulatory authority and no standing to file complaints for veterinarians. The veterinarian who has first-hand knowledge must file complaints; otherwise they are considered only hearsay.
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