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FAQ - Prescribing Rights and Formulary

What forms are needed to be filed for prescribing privileges?

First be sure you have filed the correct Supervision Data Form listing all the supervising physicians for whom you will be prescribing medications as delegated by them. The Supervising Physician must also notify the FL Department of Health of the delegated prescriptive privileges. 

Prescribing PAs are required to maintain a list of medications that their supervising physician authorizes them to prescribe. It must be signed, dated and maintained in the office and available to DOH representatives upon request. This agreement must be maintained for 5 years.

PAs must also complete 10 CME hours in the specialty practice in which they have prescriptive privileges with each licensure renewal. Three (3) of these hours must consist of a course on the Safe and Effective Prescribing of Controlled Substances as described below in more detail.

 

Where can I obtain the three-hour state-required course on the Safe and Effective Prescribing of Controlled Substances?

A three (3)-hour continuing education course on Safe and Effective Prescribing of Controlled Substances is required prior to EVERY license renewal for ALL prescribing PAs in the state of Florida. This course must be designated as American Medical Association Physician's Recognition Award Category 1 credit or designated by the American Academy of Physician Assistants as Category 1 credit.

FAPA offers an approved course sponsored by the Physicians for PA Continuing Education (PPACE) in compliance with FL Statutes, Chapter 458, regarding the safe prescribing of controlled substances. 

  • The course is available free of charge to all FAPA members. The course is also available to non-members for $75. To access the course, click here.
  • To join FAPA and receive the PPACE course for free, click here.

 

Restrictions on prescribing Medical Marijuana 

PAs/NPs are not allowed to prescribe medical marijuana. 

 

Which drugs can a prescribing PA write prescriptions for at this time?

Prescribing physician assistants are able to prescribe any medication except those specifically prohibited by the Formulary Committee of the PA council and the Boards of Medicine. The medications that physician assistants are excluded from prescribing include general anesthetics and radiographic contrast materials. While physician assistants can prescribe controlled substances, there are regulations as outlined below. Of note, the regulations were most recently changed on July 1, 2018.

Florida statute requires ALL prescribing PAs to take a three-hour continuing education course on the Safe and Effective Prescribing of Controlled Substances prior to EVERY Florida license renewal. 

Only a PA with a current license with approved prescribing privileges can write prescriptions in Florida. Prescribing PAs can prescribe any medication except those specifically excluded by law under the provisions of our Exclusionary formulary.  Also, the only medications you should write for are those medications authorized by your supervising physician within the scope of his/her practice since you are also limited to practice within the scope of your supervising physician's practice. 

In a hospital setting the law is different. You may write orders for any medications, including controlled substances. It is considered a verbal order from your supervising physician when you write it if the duty has been delegated to you. You cannot give the patient a written prescription upon discharge for any of those medications excluded by law. If it is written in the discharge orders, the nurse may call it in to a pharmacy for the patient unless it is a medication requiring a written prescription.

 

Can PAs in Florida obtain a DEA number?

As of January 02, 2017 the DEA accepts Florida applications for controlled substance prescribing.  If you are approved, a DEA number will be provided. DEA licensure is required in order to prescribe a controlled substance. The cost of DEA licensure is $731.00 for a three (3)-year license.

 

What are the regulations to controlled substance prescribing for PAs in Florida?

PAs must be delegated the authority to prescribe controlled substances by their supervising physicians.

PAs are prohibited from prescribing controlled substances in registered pain management clinics.

PAs may not prescribe psychiatric mental health controlled substances for children younger than 18 years of age

As of July 1, 2018 there are additional regulations regarding the prescribing of controlled substances by PAs:

·       For the treatment of acute pain, a prescription for an opioid drug listed as a Schedule II controlled substance may not exceed a 3-day supply

·       Under special circumstances (ie: acute pain exemption with appropriate documentation), a 7-day supply of a schedule II controlled substance may be prescribed. This is described in more detail below.

·       An emergency opioid antagonist must be prescribed in addition to the schedule II controlled substance for certain traumatic injuries as described below.

·       Prescribers are required to check the prescription drug monitoring program (PDMP) before prescribing or dispensing a controlled substance for a patient age 16 or older. The PDMP must be checked each time a prescription for a controlled substance is written.

·       Each person registered with the United States Drug Enforcement Administration and authorized to prescribe controlled substances pursuant to complete a board-approved two-hour continuing education course on prescribing controlled substances as part of biennial license renewal. The course must be completed by January 31, 2019, and at each subsequent renewal.

 

When is a PA allowed to write a prescription for a 7-day supply of a schedule II controlled substance?

1.     The prescriber, in his or her professional judgment, believes that more than a 3-day supply of such an opioid is medically necessary to treat the patient’s pain as an acute medical condition

2.     The prescriber must indicate “ACUTE PAIN EXCEPTION” on the prescription

3.     The prescriber adequately documents in the patient’s medical records the acute medical condition and lack of alternative treatment options that justify deviation from the 3-day supply limit established in this subsection.

 

What are the exceptions to “acute pain”?

Exceptions include: cancer, palliative care, terminal conditions, or traumatic injury with an Injury Severity Score of 9 or greater. There are no prescribing limitations for these conditions.

For the treatment of pain other than acute pain, a prescriber must indicate “NONACUTE PAIN” on a prescription for an opioid drug listed as a Schedule II controlled substance.

 

 

How should a prescription be written in compliance with the new controlled substance prescribing laws (effective July 01, 2018)?

 

When writing an acute pain prescription for a 3-day supply of a schedule II controlled substance:

·       Write “acute pain”

 

When writing an acute pain prescription for a 7-day supply of a schedule II controlled substance:

·       Write “acute pain exemption”

 

All new prescriptions will have two boxes to check on the prescription for “Acute pain” or “non acute pain”

 

 

 

If a PA writes a 3 day script for a schedule II narcotic post surgery and the patient calls back for refill in 4 days, is the prescriber permitted to refill a 3 day schedule II controlled substance prescription if appropriate and properly documented and reviewed in the PDMP?

 

In this situation, the prescriber should not refill the 3-day prescription. Refills are discouraged, so a new prescription should be written.

 

However, you can write another new script for 3 days or even for 7 days as long as it is appropriately documented in the medical record and the PDMP (E-FORCSE) is checked.

 

In this example - if it is known the patient will have pain post-operatively for 7 days, it is better to write a 7-day supply and include “acute pain exemption” on the prescription.

 

 

 

When does an emergency opioid antagonist need to be prescribed along with a schedule II controlled substance?

The prescriber must also prescribe an emergency opioid antagonist for the treatment of pain related to a traumatic injury with an Injury Severity Score of 9 or greater.

 

 

 

What must a prescriber do if unable to access the prescription drug monitoring program before prescribing or dispensing a controlled substance for a patient age 16 or older?

If the PDMP is nonoperational this must be documented in the patient’s chart and only a 3-day supply of the controlled substance may be given.  A designee of a prescriber or dispenser may check the PDMP.

The duty to consult the system does not apply when the system:

  • Is determined by the department to be nonoperational; or
  • Cannot be accessed by the prescriber or dispenser or a designee of the prescriber or dispenser because of a temporary technological or electrical failure

 

 

Are all prescribing PAs required to consult the prescription drug monitoring program?

The requirement does not apply when:

·       Prescribing or dispensing a nonopioid controlled substance listed in Schedule V.

·       The patient is less than 16 years old.

 

Additionally, if you do not prescribe any controlled substances you are not required to register with or consult E-FORCSE.

 

 

Where can I find more FAQs regarding the controlled substance prescribing regulations that took effect July 1, 2018?

Additional FAQs can be found at http://www.flhealthsource.gov/FloridaTakeControl/faqs

 

How does a change in employment affect my prescribing privileges?

Prescribing privileges are granted to a PA working with a specific physician or physicians after you submit the properly completed application. You may prescribe under their delegated authority while under their supervision. If you change supervising physicians you may not prescribe under your new supervising physician until you have submitted the proper forms to the state and received them back as annotated received and approved. You must submit the change of Supervising Physician Data Form and notify the DOH via letter from the supervising physician and you, the PA, that you have been delegated prescribing rights.

 

Can I sign for sample medications received from pharmaceutical representatives?

Yes, but only for those medications you are authorized to prescribe.

 

Am I required to maintain a list of drugs that I prescribe? 

Yes. Even though we have an Exclusionary Formulary, other sections of the law and Florida Administrative Code apply here. F.A.C. 64B-300.007 and 64B15-6.0037 require that each supervising physician and prescribing physician assistant shall enter into and keep on file a written agreement outlining which of the medicinal drugs in the formulary that the supervising physician has specifically authorized the prescribing physician assistant to prescribe. It must be signed and dated by all parties and maintained on file for at least five years, and be available to responsible Department of Health personnel upon request.

 

Does my supervising physician have to countersign my prescriptions?

No, as long as it is an approved drug on the formulary and included on your agreed-upon list.

 

Do I have to keep duplicate copies of the prescriptions on file?

This practice is no longer required. You must include notations in the medical record regarding the medications given the patient by you. It is recommended that you include in the note the name of the drug, strength, amount prescribed, specific directions, and refill instructions.

 

What information must be on the prescription form?

The prescription form may be paper or electronic but must comply with ss. 456.0392(1) and 456.42(1) and chapter 499 as listed on the FL BOM website. It must have the supervising physicians name, practice address, and phone number. It must also have the prescribing physician assistant's name, practice address, phone number, and prescriber number (and DEA number if prescribing for controlled substances). If you work in an office setting with more than one supervising physician, each physician must be listed on the prescription. (You can get them printed with a check box by their name so that you can check off which physician is supervising you in providing care to that particular patient, i.e., the physician whom will be countersigning the record.)

If you work in a satellite office, or another practice setting, you will need to have a prescription form for each office or setting including all the required information.

In compliance with the new controlled substance prescribing regulations (effective July 01, 2018):

When writing an acute pain prescription for a 3-day supply of a schedule II controlled substance:

·       Write “acute pain”

 

When writing an acute pain prescription for a 7-day supply of a schedule II controlled substance:

·       Write “acute pain exemption”

 

When writing a schedule II controlled substance prescription for the treatment of pain other than acute pain (as outlined above):

·       Write “NONACUTE PAIN”

 

All new prescriptions will have two boxes to check on the prescription for “Acute pain” or “Non acute pain”

 

Can PAs dispense medications?

A fully licensed physician assistant may dispense or prescribe any medication as delegated by their supervising physician except for those medications which are listed on the formulary as discussed above. The PA must also be in compliance with all regulations as listed in Florida Statute 458.347- 4(f)

 

Can a PA utilize a physician’s stamped signature for prescriptions or when ordering contrast studies?

Stamped signatures are not authorized for any purpose in regards to cosigning for a PA for anything. PAs cannot write a prescription for IV contrast materials to be dispensed directly to the patient. You can write a referral or an order for studies using contrast materials. That material is then given by the radiologist or by a technician under his/her supervision.

 

Can a PA prescribe over the internet?

In short, PAs cannot provide treatment recommendations or issue a prescription via telemedicine unless you have done a history and physical for which any drug is prescribed. You have to discuss treatment options, risks and benefits with the patient and maintain a contemporaneous medical record in accordance with current rules. The rule does not apply in an emergency situation. And it does not apply to on-call or cross-coverage situations in which the physician has access to patient records.

Here is the rule verbatim from the state website.

64B8-9.0141 Standards for Telemedicine Practice.

(1) “Telemedicine” means the practice of medicine by a licensed Florida physician or physician assistant where patient care, treatment, or services are provided through the use of medical information exchanged from one site to another via electronic communications. Telemedicine shall not include the provision of health care services only through an audio only telephone, email messages, text messages, facsimile transmission, U.S. Mail or other parcel service, or any combination thereof.

 

(2) The standard of care, as defined in Section 456.50(1)(e), F.S., shall remain the same regardless of whether a Florida licensed physician or physician assistant provides health care services in person or by telemedicine.

 

(3) Florida licensed physicians and physician assistants providing health care services by telemedicine are responsible for the quality of the equipment and technology employed and are responsible for their safe use. Telemedicine equipment and technology must be able to provide, at a minimum, the same information to the physician and physician assistant which will enable them to meet or exceed the prevailing standard of care for the practice of medicine.

 

(4) Controlled substances shall not be prescribed through the use of telemedicine except for the treatment of psychiatric disorders. This provision does not preclude physicians or physician assistants from ordering controlled substances through the use of telemedicine for patients hospitalized in a facility licensed pursuant to Chapter 395, F.S.

 

(5) Prescribing medications based solely on an electronic medical questionnaire constitutes the failure to practice medicine with that level of care, skill, and treatment which is recognized by reasonably prudent physicians as being acceptable under similar conditions and circumstances, as well as prescribing legend drugs other than in the course of a physician’s professional practice.

 

(6) Physicians and physician assistants shall not provide treatment recommendations, including issuing a prescription, via electronic or other means, unless the following elements have been met:

 

(a) A documented patient evaluation, including history and physical examination to establish the diagnosis for which any legend drug is prescribed.

 

(b) Discussion between the physician or the physician assistant and the patient regarding treatment options and the risks and benefits of treatment.

 

(c) Maintenance of contemporaneous medical records meeting the requirements of Rule 64B8-9.003, F.A.C.

 

(7) The practice of medicine by telemedicine does not alter any obligation of the physician or the physician assistant regarding patient confidentiality or recordkeeping.

 

(8) A physician-patient relationship may be established through telemedicine.

 

(9)(a) Nothing contained in this rule shall prohibit consultations between physicians or the transmission and review of digital images, pathology specimens, test results, or other medical data by physicians or other qualified providers related to the care of Florida patients.

 

(b) This rule does not apply to emergency medical services provided by emergency physicians, emergency medical technicians (EMTs), paramedics, and emergency dispatchers. Emergency medical services are those activities or services to prevent or treat a sudden critical illness or injury and to provide emergency medical care and prehospital emergency medical transportation to sick, injured, or otherwise incapacitated persons in this state.

 

(c) The provisions of this rule shall not apply where a physician or physician assistant is treating a patient with an emergency medical condition that requires immediate medical care. An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention will result in serious jeopardy to patient health, serious impairment to bodily functions, or serious dysfunction of a body organ or part.

 

(d) The provisions of this rule shall not be construed to prohibit patient care in consultation with another physician who has an ongoing relationship with the patient, and who has agreed to supervise the patient’s treatment, including the use of any prescribed medications, nor on-call or cross-coverage situations in which the physician has access to patient records.

Rulemaking Authority 458.331(1)(v) FS. Law Implemented 458.331(1)(v), 458.347(4)(g) FS. History‒New 3-12-14, Amended 7-22-14, 10-26-14, 3-7-16.

 

What do PAs need to do in order to prescribe? Is a separate prescribing license still required?  

No. As of July 1, 2012, PAs do not need a separate prescribing license in order to prescribe medications as per Florida formulary.

However, for any PAs licensed on or after July 1, 2012, or any PAs who did not have a prescribing license prior to July 1, 2012, the Physician Assistant must ask his or her supervision physician to delegate that authority to the PA. If yes, then the supervising physician writes a letter to the DOH delegating that authority to the PA. The DOH said it would be nice if they would list the specialty, but this is not required by law. Listing the specialty will help down the line with the 10-hour requirement.

Then, the PA writes a letter to the DOH requesting prescribing privileges and attaches the doctor’s letter. Then they mail it to the DOH/PA Council. It is that simple. In the end, the DOH after repeated review of the bill, agreed that only on initial licensure does a PA have to provide the course and transcript. They said they can’t require anything from currently licensed PAs other than the request and delegation by their supervising physicians.

Any changes after the fact such as supervising physician or change in practice specialty should be dealt with using the supervisory data form.

[This is only for PAs who do not currently prescribe but have been licensed previously in Florida. They are the only ones who have to send in the request and letter. If you currently have a PA prescribing number there is no change. You are already a prescribing PA so no need to do anything.]

List of Approved Medications for Inpatient/Outpatient Prescriptive Privileges

Immunosuppressive (including but not limited to the following medications):
Tacrolimus, Mycophenolate mofetil, prednisone, cyclosporine, rapamycin, basiliximab, thymoglobulin, daclizumab, sirolimus


Antibiotics (including, but not limited to the following medications):
Cefotaxime, Zosyn, cephalosporins, penicillins, batalactamases, rifaximin, bactrim, SS and DS, pentamidine, vancomycin, levaquin, ciprofloxacin, norfloxicin, flagyl, linezolid, bactroban, (topical)


Antivirals (including, but not limited to the following medications):
Acyclovir, ganciclovir, valganciclovir, cytogam, foscarnet, entecavir, lamivudine, Hepatitis B Immune Globulin, adefovir, valacyclovir, infergen, pegasys, ribavirin


Antifungals (including, but not limited to the following medications):
Amphotercin B, Fluconazole, nystatin, clotrimazole troche


Antiemetics (including, but not limited to the following medications):
Zofran, Phenergan, Compazine, Anzemet


Antihyertensives (including, but not limited to the following medications):
Norvasc, Inderal, Propanolol, Metoprolol, Captopril, Nadolol, Corgard


Thyroid Agents (including, but not limited to the following medications):
Synthroid, levoxyl


Misc. Endocrine/Metabolic agents (including, but not limited to the following medications):
Octreotide, colchicine


Other Pain Relievers (including, but not limited to the following medications):
Neurontin


Hypnotics (including, but not limited to the following medications):
Restoril, Zolpidem, Lunesta, Benedryl


Antipyretics (including, but not limited to the following medications):
Tylenol and Tylenol based products


Antithrombotics (including, but not limited to the following medications):
Lovenox, Coumadin, Heparin


Prothrombotics (including, but not limited to the following medications):
Phytonadione


Laxative (including, but not limited to the following medications):
Dulcolax PO, and suppositories, fleets enemas, colace, lactulose


Antidiarrheals (including, but not limited to the following medications):
Immodium


Diabetic Agents (including, but not limited to the following medications):
Insulin (Novolog, Regular, Humalog, G – largine)


PPI’s (including, but not limited to the following medications):
Previcid, aciphex, protonix, prilosec, nexium


Antipsychotics (for use in the hospital only) (including, but not limited to the following medications):
Haldol, Zyprexa, Seroquel


Antidepressants (including, but not limited to the following medications):
Lexapro, Celexa, Prozac, Zoloft, Nortryptyline, Remeron, Cymbalta


Anxiolytics (including, but not limited to the following medications):
Xanax, Ativan, Valium


Inhalers (including, but not limited to the following medications):
Xopenex, Albuterol, Ipratropium, Atrovent


Misc.Gastric Agents (including, but not limited to the following medications):
Maalox, Mylanta, magnesium hydroxide, peptobismol


Antiseizure Medications (including, but not limited to the following medications):
Keppra


Narcotic Pain Medications (including, but not limited to the following medications):
Demerol, Morphine, Dilaudid, Darvocet, Oxycodone, Oxycontin, Percocet, Vicodin, Toradol, Fentanyl duragesic patch


Narcotic Antidote (including, but not limited to the following medications):
Narcan


Alpha Adrenergic Agonist, Vasopressor (including, but not limited to the following medications):
Midodrine


Topical Creams/Emollients (including, but not limited to the following medications):
Vanicream, silvadene cream


Vitamins/Minerals (including, but not limited to the following medications):
Multivitamins, B, C, D, E, calcium, phos lo, K Dur, potassium chloride, magnesium oxide, magnesium sulfate, K phos neutral, sodium phosphate, vitamin K sodium bicarbonate

 

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