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Authority: NAC In either case the pharmacist must: 1 Note the quantity supplied with the original prescription, and 2 Fill any quantity of the remaining portion that is requested no later than 30 days of the date the prescription was issued. There is no limit to the number of times a prescription can be partially filled within the 30 days so long as the total quantity in all partial fillings does not exceed the total quantity that was prescribed. If a CII is written on the same prescription with another drug, the pharmacy must:. Generally a pharmacist cannot fill a CII prescription unless it is tendered by the pharmacy on or before the 14th day after the date of issue. Authority: NRS
Some states, however, do impose specific limits on the amount of a schedule II controlled substance that may be prescribed. Any limitations imposed by state law apply in addition to the corresponding requirements under Federal law, so long as the state requirements do not conflict with or contravene the Federal requirements. Again, the essential requirement under Federal law is that the prescription for a controlled substance be issued for a legitimate medical purpose in the usual course of professional practice.
In addition, physicians and pharmacies have a duty as DEA registrants to ensure that their prescribing and dispensing of controlled substances occur in a manner consistent with effective controls against diversion and misuse, taking into account the nature of the drug being prescribed.
Effective date of prescription : Two commenters requested that DEA clarify the effective date of a sequential prescription for a schedule II controlled substance. Some commenters pointed out that some states stipulate "effective dates" for prescriptions, noting that these states have laws which require that, to be valid, prescriptions must be filled within a certain time after they are written, and that these time limits differ by state. Some commenters noted that if the time limit starts on the date all the sequential prescriptions are written, then it cannot be used in some states.
If the effective date starts on the "Do not fill until" date on the second and third prescriptions, then it will be valid in many more states. Three commenters requested clarification as to whether it is legally permissible for a practitioner to issue a single prescription with "Do not fill before [date]," in which the "Do not fill" date is, for example, days in the future. The DEA regulations require that all prescriptions for controlled substances "be dated as of, and signed on, the day when issued.
This Final Rule does not amend the regulations regarding the date of issuance of a prescription. Under longstanding federal law and DEA regulations, there is no express requirement that a prescription be filled within a certain time after it was issued.
The proposed rule likewise contained no such express requirement, as DEA believes that the requirements contained in the proposed rule provided adequate safeguards against diversion. At the same time, the proposed rule made clear that the issuance of multiple prescriptions is permissible only if "the individual practitioner complies fully with all other applicable requirements under the [CSA] and [DEA] regulations as well as any additional requirements under state law.
To make this point unambiguous, the countryconnectionsqatar.comM also stated that "nothing in this proposed rule changes the requirement that physicians must also abide by the laws of the states in which they practice and any additional requirements imposed by their state medical boards with respect to proper prescribing practices and what constitutes a bona fide physician- patient relationship.
The proposed rule did not address whether a single prescription with "Do not fill before [date]" instructions is permissible. Accordingly, there is no prohibition on doing so under the CSA or DEA regulations, provided the practitioner otherwise complies fully with all applicable requirements of federal and state law.
Insurance reimbursement considerations : Four commenters requested further relaxation of the regulations to allow a day supply of schedule II controlled substances to be dispensed at one time because, these commenters asserted, this would significantly decrease the cost of the medications to the patients through their health insurance. One commenter also recommended permitting the pharmacy to dispense a day supply on one prescription, making it available in day intervals, but allowing the patient to pay for the entire supply at one time to save on the cost of the medication.
DEA response : It is beyond the scope of DEA's authority under the CSA to take regulatory action for the specific purpose of affecting the manner in which patients pay for the medications or the manner in which insurance providers reimburse patients for such costs. As mentioned previously, the CSA and DEA regulations contain no specific limit on the number of days' worth of a schedule II controlled substance that a practitioner may authorize per prescription. Limitations regarding certain medications : Three commenters supported the use of sequential prescriptions specifically for schedule II controlled substances used to treat ADD or ADHD, but disagreed with the use of sequential prescriptions for schedule II controlled substances used in the treatment of pain.
Commenters believed pain patients should be seen and evaluated every 30 days and have medications prescribed at that time. One commenter requested that DEA include explicit language indicating that this regulation is applicable to all patients being treated for ADHD with stimulant medications. Conversely, one commenter supported the use of sequential prescriptions only for narcotic schedule II controlled substances, or pain medications.
Another commenter suggested rescheduling methylphenidate and amphetamines, except methamphetamine, to separate them from pain medications because the two populations for ADHD medications and pain medications are different.
DEA response : This rule pertains to all schedule II controlled substances, not just those substances intended or approved to treat certain conditions. As DEA stated in the September 6,Policy Statement published in conjunction with the Notice of Proposed Rulemaking 71 FRit is certainly appropriate for prescribing practitioners and medical oversight boards to explore questions regarding appropriate treatment regimens for particular categories of controlled substances.
Moreover, it might indeed be beneficial toward preventing diversion and abuse of controlled substances for prescribing practitioners to see patients at regular intervals when prescribing certain controlled substances for certain medical conditions. However, as the Policy Statement made clear, DEA does not regulate the general practice of medicine and the agency lacks the authority to issue guidelines that constitute advice on the general practice of medicine.
DEA wishes to reiterate the general principle that the prescribing practitioner must properly determine there is a legitimate medical purpose for the patient to be prescribed the controlled substance and must be acting in the usual course of professional practice. Similarly, a pharmacy has a corresponding responsibility in this regard. DEA may not reschedule a substance merely based on the population it is intended or approved to treat.
Language on sequential prescriptions : Two commenters suggested not limiting the language on the prescription to "Do not fill before [date]. One commenter suggested requiring a standardized method for dating prescriptions, and considering prescriptions void if that standard is not adhered to.
Another commenter recommended that specific indication should be provided regarding sequential prescriptions by including "1 of 3," "2 of 3," and "3 of 3" on the prescriptions. DEA response : The Final Rule states that the individual practitioner must "[provide] written instructions on each prescription other than the first prescription, if the prescribing practitioner intends for that prescription to be filled immediately indicating the earliest date on which a pharmacy may fill each prescription.
Post dating cii prescriptions
DEA believes this is a sufficiently clear rule that practitioners will be able to understand and carry it out and, therefore, it is unnecessary to insist on a particular scripted approach. Likewise, under this Final Rule, a practitioner may-but is not required to-do as the commenter suggested and write on the sequential prescriptions, "1 of 3," "2 of 3," and "3 of 3", so long as each prescription complies fully with all the requirements of this Final Rule, including that it contains specific instructions regarding the earliest date on which the sequential prescription may be filled.
DEA response : DEA appreciates that the underlying intent of this comment is to ensure that the "Do not fill until [date]" instructions were actually written by the practitioner, as opposed to being the result of forgery.
While DEA supports all efforts of practitioners to take steps to prevent forgery in the context of prescriptions, the agency believes it is unnecessary to adopt the particular added requirement suggested by this commenter. One commenter recommended that certain diagnostic codes, known as ICD-9 codes, should be written by the practitioner in their own handwriting on the face of the prescription.
DEA response : DEA has not previously required that prescriptions contain such diagnostic information, and the agency does not believe that such requirement is necessary to prevent diversion and abuse of controlled substances when issuing multiple prescriptions in accordance with the rule being issued today.
Post-dating of prescriptions : One commenter recommended allowing post-dated prescriptions so the practitioner does not have to use space on the prescription blank for the phrase "Do not fill before [date].
DEA response : The DEA regulations have always required that all prescriptions for controlled substances "be dated as of, and signed on, the day when issued. This requirement is essential to monitor compliance with all provisions of the CSA and DEA regulations relating to the prescribing and dispensing of controlled substances, including but not limited to the requirement that a controlled substance be dispensed, including prescribed, only for a legitimate medical purpose by a practitioner acting in the usual course of professional practice.
Accordingly, it would be inappropriate to allow post-dating of prescriptions under any circumstance, including when issuing multiple prescriptions under the Final Rule being issued today.
Return of unfilled prescriptions : One commenter suggested that a patient return to the practitioner unfilled prescriptions if issued for sequential dispensing if the practitioner changes the medication and before the patient can receive a new prescription, as compared with simply destroying the previous prescriptions.
The commenter asserted this would help to ensure that the previously-issued prescriptions will not be filled and diverted. Thus, regardless of whether the practitioner writes a single prescription or issues multiple prescriptions at the same time under the Final Rule being issued today, there is no mandatory procedure for handling unfilled prescriptions. In all situations, however, practitioners should use common sense in determining what steps are appropriate to prevent diversion in view of the particular patient's circumstances.
While not required under the CSA or DEA regulations, it would be acceptable-and may even be the preferred practice-for a practitioner to ask the patient to return unfilled prescriptions for controlled substances, or for a patient to voluntarily do so.
Pharmacies and dispensing of sequential prescriptions : One commenter recommended that DEA clarify what a pharmacy is permitted to do if a prescription is written for 30 days and the month has 31 days e. The commenter also asked whether a pharmacist who fills a sequential prescription a day before the date stated because the pharmacy will be closed on the date the sequential prescription may be filled e.
Other commenters asked similar questions as to whether a pharmacist may fill sequential prescriptions earlier than the date specified by the prescribing practitioner.
One commenter requested that DEA allow some language for a pharmacist's "good judgment" rather than having as an absolute that sequential prescriptions cannot be filled before the "Do not fill" date. At the very least, the commenter recommended that DEA include a statement of its intent to use enforcement discretion in these cases.
Two commenters recommended that DEA clarify whether pharmacists can fill a sequential prescription before the "Do not fill" date 1 if the practitioner has not been contacted and 2 if the practitioner has been contacted. Three commenters requested that DEA clarify whether pharmacies are held accountable for filling the sequential prescriptions before the indicated date.
Two commenters suggested that the Final Rule clarify any implications or responsibilities for the dispensing pharmacy. DEA response : As explained in the countryconnectionsqatar.comM, the requirements contained in the proposed rule were included to ensure that the rule can be reconciled with the text, purpose, and structure of the CSA.
This includes, but is not limited to, adherence to the principles of requiring a written prescription for a schedule II controlled substance.
The Final Rule being issued today states expressly that, where a practitioner has issued multiple prescriptions in accordance with the rule, no pharmacist may fill any prescription before the date specified by the practitioner.
The rule contains no exceptions to this requirement. Section DEA response: DEA believes such a revision is unnecessary as it is clear from the text of the rule that it is permissible to issue multiple prescriptions in the manner specified in the rule. Use of the term "properly": Section DEA response : Although the language of the proposed rule was meant simply to reiterate and not modify the meaning of the longstanding requirement that a controlled substance be dispensed for a legitimate medical purpose by a practitioner acting in the usual course of professional practice, DEA has decided to revise section Specifically, DEA has revised this paragraph to more closely track the pertinent language contained in the longstanding regulation 21 CFR The paragraph being finalized today reads: "Each separate prescription is issued for a legitimate medical purpose by an individual practitioner acting in the usual course of professional practice.
One commenter requested that DEA state whether this imposes a new standard on practitioners.
Jul 01, Does post-dating the prescription for a CII by the prescriber void the prescription? A: The prescription must have the date it was written on the hard copy. For more information call the DEA office at A. A practitioner may provide individual patients with multiple prescriptions for the same schedule II controlled substance to be filled sequentially. The combined effect of these multiple prescriptions is to allow the patient to receive, over time, up to a day supply of that controlled substance. No I don't think you are looking for Post+dating+cii+prescriptions the impossible. Lots of women Post+dating+cii+prescriptions enjoy casual sex, the problem is they don't advertise it. I think online is your best go, and even though you have not had much luck it could be the way Post+dating+cii+prescriptions you are presenting yourself. Be honest but not blunt/
Eleven commenters recommended deleting the paragraph in its entirety. Commenters believed that the practitioner cannot account for all possible scenarios in making this conclusion. Commenters stated that the potential liability problem for practitioners is that their conclusions and prescribing actions could come into question any time a patient was implicated in abuse or diversion.
Commenters believed that practitioners will waste valuable patient time documenting why issuing sequential prescriptions does not cause undue risk.
Commenters believed it could also cause the unintended consequences of practitioners avoiding prescribing a medication the patient needs for fear of liability in court. DEA response : Since the inception of the CSA, it has always been a requirement that all DEA registrants manufacturers, distributors, practitioners, pharmacies, researchers, importers and exporters take reasonable steps to prevent their DEA registrations from being used in a manner that results in an undue risk of diversion.
This requirement is inherent in the CSA registration provisions 21 U. For example, 21 CFR Under this Final Rule, practitioners who prescribe controlled substances are subject to the same standard in preventing diversion as they always have been under the CSA and DEA regulations.
Thus, section Further, as DEA stated in the Policy Statement 71 FRpublished alongside the countryconnectionsqatar.comM, "one cannot provide an exhaustive and foolproof list of 'dos and don'ts' when it comes to prescribing controlled substances for pain or any other medical purpose.
DEA has an obligation to carry out all regulatory requirements in a reasonable manner, consistent with the governing statutes enacted by Congress, and to take into account all circumstances of the particular case at issue.
The agency will do so with regard to all cts of this Final Rule, including section Nothing in this paragraph b shall be construed as mandating or encouraging individual practitioners to issue multiple prescriptions or to see their patients only once every 90 days when prescribing Schedule II controlled substances.
Rather, individual practitioners must determine on their own, based on sound medical judgment, and in accordance with established medical standards, whether it is appropriate to issue multiple prescriptions and how often to see their patients when doing so. In this context, two commenters suggested deleting the words "in accordance with established medical standards.
Red Flags When Filling Controlled Substance Prescriptions
DEA response : The requirement that a prescription for a controlled substance be issued in accordance with established medical standards has been an integral part of federal law for decades and has been upheld by the. United States Supreme Court. Moore, U. Pharmacies and dispensing of sequential prescriptions : In section One commenter suggested the following additional language to section DEA response : It has always been the case under the CSA and DEA regulations that a pharmacist who fills a prescription for a controlled substance has a corresponding responsibility to ensure that the prescription was issued for a legitimate medical purpose by an individual practitioner acting in the usual course of professional practice.
This requirement, which is set forth in 21 CFR DEA believes it is not necessary to modify or expand upon this longstanding requirement in the context of multiple schedule II prescriptions, so long as the prescribing and filling of such prescriptions takes place in accordance with all the provisions of this Final Rule. Electronically transmitted prescriptions : Four commenters recommended DEA allow electronically transmitted prescriptions for controlled substances.
DEA response : DEA notes that the electronic prescribing of controlled substances is outside the scope of this rulemaking. DEA intends to address electronic prescribing of controlled substances in a separate future rulemaking. Authorization to use sequential prescriptions prior to publication of Final Rule : Two commenters requested that DEA allow practitioners to begin issuing multiple schedule II prescriptions based on the issuance of the countryconnectionsqatar.comM without waiting for a Final Rule to be published and to take effect.
DEA response : Under the Administrative Procedure Act APAwhen an agency seeks to impose a new substantive rule that modifies legal obligations of members of the public, the agency must first engage in notice-and-comment rulemaking 5 U.
The APA further provides that substantive rules may not take effect until at least 30 days after publication of the final rule 5 U. Exceptions to these procedural requirements can be made only "when the agency for good cause finds and incorporates the finding and a brief statement of reasons therefor in the rules issued that notice and public procedure thereon are impracticable, unnecessary, or contrary to the public interest" 5 U.
DEA has not found that there is such a legal justification to exempt this Final Rule from the basic procedural requirements of the APA. Accordingly, this Final Rule does not take effect until the effective date indicated herein December 19, Long Term Care Facilities : One commenter asked if this rule will apply to patients in long term care facilities. DEA response : The DEA regulations contain a variety of provisions relating to the dispensing of controlled substances at long term care facilities.
These provisions are unaltered by this Final Rule. This Final Rule may be utilized in the context of a long term care facility, provided such activity complies with any other applicable provisions of the DEA regulations. Miscellaneous: One commenter recommended that DEA make one federal rule regarding prescriptions to supersede the many different state laws.
This is reflected in 21 U. Thus, each state may enact controlled substance laws that go beyond the requirements of the CSA, provided such laws do not conflict with the CSA. Given this ct of the CSA, it would not be appropriate for DEA to seek to preempt or supersede state laws relating to the prescribing of controlled substances, provided such laws do not conflict with the CSA or DEA regulations.
One commenter suggested DEA work with other federal agencies and national professional medical societies to be certain doctors are screening for alcoholism and drug addiction in their private medical practices as they are prescribing schedule II controlled substances in the treatment of legitimate medical illnesses. DEA response : DEA firmly supports all efforts of practitioners to screen for factors that might be indicative of whether the patient may be likely to seek controlled substances for purposes of abuse or to satisfy an addiction.
However, such a consideration is beyond the scope of this Final Rule. Three commenters recommended that DEA explain existing law and the impact of the new rule to health care professionals, state attorneys general, drug control officials, and professional licensing and regulatory boards.
DEA response : DEA works cooperatively with a wide variety of organizations who have an interest in the CSA and DEA regulations and policies, including, but not limited to: State Boards of Medicine and Boards of Pharmacy; law enforcement; regulatory and professional licensing authorities and agencies; the pharmaceutical industry; and professional organizations representing prescribing and dispensing practitioners.
DEA meets regularly with these organizations to discuss matters of mutual concern. Included in these meetings are discussions of DEA legal and regulatory activities. One commenter suggested allowing partial filling of schedule II prescriptions so as not to constitute a refill. Adherence to this ct of the DEA regulations serves a critical function in preventing diversion of schedule II controlled substances. Accordingly, this Final Rule does not modify the requirements of the DEA regulations relating to the partial filling of prescriptions.
Treatment of Pain Patients : Nineteen commenters opposed the countryconnectionsqatar.comM because they believed that, for a patient who is receiving controlled substances for the treatment of pain, the practitioner should see the patient more than once every 90 days to properly monitor the.
These commenters asserted that such a patient should see the practitioner every 30 days because treatment for pain does not consist of medication alone. One commenter stated that he had a family member who became addicted to schedule II controlled substances that were prescribed for pain and whose quality of life diminished significantly as a result. This commenter therefore objected to "slackening the restrictions on these highly addictive and destructive drugs.
DEA response : DEA recognizes, as these comments reflect, that some practitioners believe that seeing a patient who is receiving controlled substances only once every 90 days is inadequate. However, the CSA does not expressly address how frequently a practitioner must see a patient when prescribing controlled substances. At the same time, practitioners who prescribe controlled substances must see their patients in an appropriate time and manner so as to meet their obligation to prescribe only for a legitimate medical purpose in the usual course of professional practice and to thereby minimize the likelihood that patients will abuse, or become addicted to, the controlled substances.
In this regard, section Nothing in this section shall be construed as mandating or encouraging individual practitioners to issue multiple prescriptions or to see their patients only once every 90 days when prescribing Schedule II controlled substances. Diversion : One commenter opposed the countryconnectionsqatar.comM, asserting that a practitioner cannot always tell whether he or she is "getting scammed" by a patient seeking drugs for abuse.
This commenter suggested that, if a practitioner is being deceived by such a patient, the harm will be less if the prescription is only for a day supply of a controlled substance rather than a day supply. Another commenter opposed the countryconnectionsqatar.comM because the commenter believed that drug abusers will change the dates on the multiple prescriptions and have all the multiple prescriptions filled at once by different pharmacies. Another commenter, who indicated she worked in a pharmacy, expressed the view that drug addicts will see multiple practitioners in a day period to obtain overlapping day supplies of schedule II controlled substances.
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DEA response : It is true that, other factors being equal, the diversion of a day supply of controlled substances causes greater harm than the diversion of a day supply.
Likewise, the adverse effects of any improper conduct on the part of a drug-seeking patient such as "doctor shopping" or seeing multiple prescribing practitioners will be magnified if the patient is receiving a day supply of a schedule II controlled substance as opposed to a day supply.
However, for the reasons provided in responding to the preceding comments, DEA believes it is appropriate to allow for up to a day supply of schedule II controlled substances under the conditions set forth in this Final Rule-with the understanding that 90 days is the upper limit and by no means mandatory.
Can a pharmacist accept a faxed CII prescription? Generally no. A CII prescription can be faxed by a practitioner to a pharmacy only when: The controlled substance will be compounded for the direct administration to a patient by parenteral, intravenous, intramuscular, subcutaneous or intraspinal infusion; The controlled substance is issued to a resident of a facility for long-term care; OR The controlled substance is issued to a patient enrolled in a licensed program that provides hospice care.
Can a CII be written on the same prescription along with a prescription for another drug?
What can a pharmacist not add or change to a CII prescription?
Make a copy of the original prescription for each of the other prescriptions written on that prescription; and File the copy or copies in the files appropriate for those drugs. Each copy made must include a reference to the prescription number for the CII listed.
Feb 02, Post dated prescriptions are illegal. Some states allow C2s to have earliest fill dates listed on the pad but a C2 must be dated the day it was signed. Post-dating of prescriptions: One commenter recommended allowing post-dated prescriptions so the practitioner does not have to use space on the prescription blank . The date indicated by the practitioner must not be later than 3 months after the date on which the prescription is written. Federal law prohibits the issuance of more than a day supply using post-dated prescriptions.
If the prescription blank contains more than one controlled substance listed in schedule II, include on each copy of the prescription a reference to the serial number of the first prescription for a controlled substance listed in schedule II. How does the day rule apply to CII prescriptions?
Can a CII prescription be post-dated? Federal law prohibits the issuance of more than a day supply using post-dated prescriptions. Can a CII prescription be written for more than a one month supply? Can a prescribing practitioner prescribe medication for a family member?
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