During the 2018 General Assembly, the Iowa Legislature and Governor Reynolds enacted House File 2377 which included a mandate that, as of Jan. 1, 2020, all prescriptions (controlled and non-controlled substances) must be transmitted electronically from prescriber to pharmacy. The Iowa Code identifies certain prescriptions which would be exempt from this mandate. The Iowa Code also authorizes the Board to grant temporary exemption to entities that may not be compliant by Jan. 1, 2020. A temporary exemption may be considered for entities that can demonstrate economic hardship, technological limitations, or other exceptional circumstances.
Rules
The Board’s rules relating to the mandate for the electronic transmission of prescriptions, as adopted July 10, 2019. The Board’s adopted rules were published in the July 31, 2019 Iowa Administrative Bulletin and became effective September 4, 2019.
Petition for Exemption
A prescriber or pharmacy may petition the Board for temporary exemption from the mandate if the prescriber or pharmacy has an economic hardship, technological limitation(s), or other exceptional circumstance(s). To request an exemption, submit a completed petition form and any additional documentation that you wish for the Board to consider. Petitions received three or more weeks in advance of a scheduled Board meeting will be placed on the agenda for consideration at the next meeting. Petitions received less than three weeks in advance of a scheduled Board meeting will not be placed on the agenda for consideration until the following meeting.
Iowa Code
The Iowa Code section which relates to mandated electronic prescribing of controlled substances may be found in 124.308. The Iowa Code section which relates to mandated electronic prescribing of non-controlled substances may be found in 155A.27.
Electronic Prescribing Vendors
Providers must conduct independent research to identify a vendor that will work with the business practice. The Board does not endorse any particular vendor. The Board does not mandate electronic health record (EHR) systems, nor does it mandate the electronic prescription system be integrated into an EHR system.
Bandwidth Map
The Office of the Chief Information Officer has developed a map to identify the status of bandwidth in Iowa.
Exempt Providers
Businesses are responsible for maintaining a list of prescribers who are covered by their exemption. The exemption only covers those prescribers while they are working in the capacity described in the petition.
Frequently Asked Questions
Prescriber Questions
General Questions, Prescription Exemptions, and Care Facilities
Electronic prescribing describes the transmission of a prescription to a pharmacy via a secure electronic portal. Electronic prescribing does NOT include faxing a prescription image to the pharmacy.
Iowa Code sections 155A.27 and 124.308 mandate the electronic transmission of all prescriptions.
Unless an authorized prescription is issued pursuant to an exemption as outlined by the legislature, the prescription must be submitted to a pharmacy through an electronic prescribing platform. Prescriptions that are written in violation of the electronic prescribing mandate are still valid prescriptions and may be filled by pharmacists. However, violating the mandate may result in a fine to the prescriber of $250 per occurrence.
As a prescriber, I am wondering who is going to decide if you meet one of the exemptions? And when will that be decided? Can we still call in rx’s, and will that be held up till someone decides its “OK” and meets the exemptions? Will each provider get so many exemptions a month?
It is up to the individual prescriber to determine whether or not a particular situation or scenario fits within any of the many codified exemptions within the e-prescribing mandate. A pharmacist may fill an otherwise valid prescription regardless of the method of transmission. The pharmacist does, however, have a professional responsibility to report any suspected violations of the e-prescribing mandate to the Board or the practitioner's primary licensing board. It will then be up to the prescriber's primary licensing board to assess the penalty and enforce the e- prescribing mandate. You may need to explain your use of an exemption to your professional licensing board, if requested.
Our organization is implementing the Electronic Prescribing of Controlled Substances. I have a physician who states according to code she can have an "authorized agent" (such as her nurse) upon her verbal order go and complete the e-prescription on her behalf for controlled substances. Curious as to how then we would set the nurse up as an authorized agent through identity proofing etc. Can you please clarify? Please note, the mandate is required for all prescriptions, not just controlled substances.
Review IAC 657 10.24 which provides the rules for prescription requirements of controlled substances. A prescriber may ask an assistant to write or type the prescription or to prepare an electronic prescription but the prescriber is responsible for ensuring that all information is correct and the prescriber must manually or electronically sign the prescription, as appropriate. As to your question about how to set it up, this is something you would need to work with your software vendor on implementing.
Yes, changes can be made over the phone. The original transmission is still valid and the pharmacy can electronically annotate the prescription in the system. Additionally, systems may have the capability to forward prescriptions to another pharmacy, reject a prescription back to the prescriber, and request changes.
Yes, each prescription which is transmitted electronically must include the phone number at which the prescriber may be reached for timely consultation with the pharmacist, if needed.
Iowa Code 155A.27 and 124.308 exempt prescriptions:
- For a patient residing in a nursing home, long-term care facility, correctional facility, or jail
- Authorized by a licensed veterinarian
- For devices
- Dispensed by a department of Veterans Affairs pharmacy
- Requiring information that makes electronic transmission impractical, such as complicated or lengthy directions for use or attachments
- For compounded preparations containing two or more components
- Issued in response to a public health emergency in a situation where a non-patient specific prescription would be permitted
- Issued for an opioid antagonist pursuant to Iowa Code section 135.190 or issued for epinephrine pursuant to Iowa Code section 135.185
- Issued during a temporary technical or electronic failure at the location of the prescriber or pharmacy, provided that the prescription indicates the temporary technical or electronic failure
- Issued pursuant to a collaborative practice agreement, standing order, drug research protocol
- Issued in an emergency situation
An emergency situation may include, but is not limited to, the issuance of a prescription to meet the immediate care need of a patient after hours when a prescriber is unable to access electronic prescribing capabilities. Such prescription shall be limited to a quantity sufficient to meet the acute need of the patient with no authorized refills. An emergency situation could also include when a prescriber does not have access to electronic prescribing capabilities, such as when workflow or operations must be adjusted in response to the challenges posed by the novel coronavirus (COVID-19). Note that enforcement of the mandate lies with the prescriber’s professional licensing board, not the Board of Pharmacy, and practitioners should consult with their licensing board for further guidance.
It depends. Iowa Code 155A.27 requires the electronic transmission of prescriptions for drugs to pharmacies. Since FDA defines medical gases as drugs, they would be subject to the mandate. However, if the prescription is being transmitted to a limited distributor for patient dispensing, the mandate would not apply.
No. The e-prescribing mandate is found in Iowa Code 155A (practice of pharmacy) and Iowa Code 124, Iowa’s Controlled Substances Act. Therefore, orders for tests or x-rays would not be included in the mandate.
Are we under the umbrella for a correctional facility or jail?
Yes
The e-prescribing mandate requires that all prescriptions be transmitted electronically to a pharmacy, unless the prescription falls within one of the enumerated exceptions.
Any drug that is administered to a patient at an outpatient dialysis center in Iowa does not require transmission of a prescription; therefore, the e-prescribing mandate is not implicated for these administrations. The term drug includes hypertonic and isotonic fluids.
If a dialysis patient is prescribed a medication that will be dispensed at a pharmacy, the prescriber will be required to transmit that prescription to the pharmacy electronically, unless one of the exceptions is applicable.
When treating a patient who has a positive sexually transmitted disease and we do not have enough information on the partner to build them into an electronic prescription program, can the providers give the patient a written script for their partner?
Expedited partner therapy prescriptions for unnamed partners would be exempt from the e-prescribing mandate because electronic transmission is impractical without patient identifying information.
Yes. The board does not have jurisdiction to license pharmacies located in other countries. As such, the electronic transmission mandate would not apply in this situation because the pharmacy is not subject to the laws of this state.
The Board cautions this practice and reminds practitioners that FDA warnings have been issued to report that online pharmacies that purport to sell drugs from Canada, Britain, Australia, etc., may actually get their drugs from other countries, which would increase the risk that consumers are receiving counterfeit or illegitimate drugs. Should a patient or consumer wish to obtain prescription drugs from an online pharmacy, the National Association of Boards of Pharmacy maintains a list of authenticated online pharmacies that have been vetted for compliance. Consumers can quickly and easily identify authenticated online pharmacies as they will be operating under a dot pharmacy (.pharmacy) domain.
No. Iowa Code 155A.27 exempts from the electronic transmission mandate prescriptions issued for patients residing in a nursing home, long-term care facility, correctional facility, or jail. The Iowa Department of Aging identifies Assisted Living facilities as “long-term care.”
Again, the resident will technically be in the NF until after the order is written.
Mandated PMP utilization is governed by the prescriber’s primary licensing Board. Therefore, this question would be most appropriately addressed by the individual practitioner's licensing Board.
They are a nursing home patient and are exempt from the electronic prescription mandate.
Yes.
Cost, Exemptions for Providers, Hospice, Hospital, InstyMeds, Jails and Prisons, Non-resident, Penalties, & Refills
The cost to set up and use an electronic prescribing system varies by vendor and contract.
Prescribers who issue less than 50 prescriptions for noncontrolled substances per year may seek a board exemption to the mandate. Request a low volume exemption using our online form.
The Board will respond to petitions for exemption with both an email and letter after the petitions have been reviewed.
A prescriber who is seeking an exemption due to financial hardship must include sufficient documentation in the petition to support the justification and demonstrate the financial hardship created.
This situation could fall under the temporary technical/electronic failure exemption. A prescription issued during a temporary technical or electronic failure at the location of the prescriber or pharmacy shall indicate on the prescription that the prescriber or pharmacy is experiencing a temporary technical or electronic failure.
If a prescription is issued under the temporary electronic failure, it must be notated on the prescription. For other exemptions, it is recommended (but not required) to note the specific exemption on the prescription.
The scenario provided is not listed as a codified exemption to the e-prescribing mandate. The prescription could be e-prescribed to the patient's primary pharmacy or the pharmacy of the patient’s choice with a note to the pharmacy stating "contact patient with price prior to filling." Then the patient can obtain the pricing information and shop around for a better price. The patient may transfer the electronic prescription for non-controlled medication to the pharmacy of their choice.
We are a small private college with an on-campus health clinic with contracted providers that come to campus. With our current model, we have providers write on paper prescription pads and we fax to our local pharmacies that deliver to campus/Health Service. How might we qualify for an exemption due to the fact that we do not yet have the capability to transmit prescriptions electronically at this time?
The law does not exempt this as an exemption to the mandate; however, the clinic may seek an exemption from the Board.
If a prescriber works for the VA and the patient has opted to have a prescription filled at a pharmacy outside the VA system, does the prescription have to be electronically transmitted?
It depends.
- If the VA practitioner is licensed with a professional prescriber board in Iowa, the mandate would apply to any prescription to be filled at a pharmacy outside the VA system, unless federal law supersedes Iowa law. Pursuant to board rule 657-21.(9)”2”, a VA system may seek an exemption for these prescriptions.
- If the VA practitioner is not an Iowa-licensed practitioner, the mandate does not apply.
Our facility is not licensed as a nursing home or long-term care facility but rather provides general inpatient, respite, and routine hospice care. Are controlled substances prescribed to patients in this facility excluded from the EPCS mandate?
Yes. The law does not require state licensure of a facility to fall under the exemptions to the electronic prescribing mandate. An inpatient hospice facility could be treated the same as a care facility for the purpose of the mandate.
No. Outpatient hospice prescriptions would not be exempt. Only inpatient care facilities have the exemption, so any outpatient prescription would be subject to the electronic transmission mandate.
It depends.
- Iowa Code 155A.27 and 124.308 require electronic transmission of “prescriptions.” In the hospital setting, when prescribers issue medication “orders” for inpatient administration, they are not subject to the electronic transmission mandate.
- If the prescriber is issuing a prescription for the patient at discharge, for the patient to have the medication to self-administer in an ambulatory (i.e. home, not LTC, etc.) setting, then the prescription would be subject to the electronic transmission mandate.
Sometimes the facility does not have control over which provider is sent, and it can take five to seven days to get a provider permission to use the hospital system.
The onus is on the locums providers and providers in general to ensure prescriptions are transmitted in a compliant manner. Best practice would be to ensure, when writing contracts with provider agencies, to require that a provider must be registered with your system before they are sent to provide coverage at your facility. If they have not completed the permissions process, they should bring some sort of mobile device that allows them to transmit the prescriptions in the required fashion.
If the InstyMeds (or whatever outpatient point-of-care automated dispensing system is in use) operates as prescriber dispensing, then there is no transmission of a prescription to a pharmacy and the e-prescribing mandate does not apply.
If the InstyMeds (or other automated dispensing system) operates under a hospital
pharmacy license, then the e-prescribing mandate does apply and sending prescriptions electronically to the InstyMeds (or other automated dispensing system) would satisfy the mandate. As it relates to controlled substances, the facility needs to verify with InstyMeds (or other automated dispensing system) that the electronic prescribing application or process complies with federal regulations for the electronic prescribing of controlled substances. InstyMeds (or other automated dispensing system) must be able to provide documentation that the system has been audited and deemed compliant with federal e-prescribing regulations.
If so, do we fill out any form to submit to someone? Also when these juveniles get discharged from us, we usually send them with a 30 day prescription. We can usually call in for other meds but we do actual paper prescriptions for the C-IIs. How would that work for us?
The residents of your training school, because they are adjudicated, would meet the e-prescribing exemption for jails/prisons. However, when they are discharged from the program, the prescriptions that are authorized to be filled in the retail/community setting would be subjected to the e-prescribing mandate.
The Board will respond to petitions for exemption with both an email and letter after the petitions have been reviewed.
It depends. The mandate only applies when both the prescriber and the pharmacy are subject to Iowa laws and rules.
- If the prescriber is located out of state and the Iowa patient is treated in that state, the prescriber is not required to be licensed in Iowa and, thus, not subject to the electronic mandate. The prescriber may issue a prescription in any lawful manner for the patient to be filled at a pharmacy of the patient’s choice.
- If the prescriber is located out of state and treating the Iowa patient while located in Iowa (telemedicine or traveling provider), the prescriber is required to be licensed in Iowa and would be subject to the electronic transmission mandate when submitting a prescription to an Iowa-licensed pharmacy.
The professional licensing board of the prescriber is authorized by Iowa law to administer a $250 civil penalty for each instance of noncompliance (each prescription transmitted in violation), up to a maximum penalty of $5,000 per year.
The rules governing prescription refills have not changed.
- For noncontrolled medications, up to 12 refills may be included on a prescription which is valid for 18 months
- For controlled substances, you may issue up to five refills on schedule III-V controlled substances which are valid for up to six months. Schedule II controlled substances may not be refilled. However, you may issue up to three schedule II prescriptions at a time to be filled subsequently, noting the earliest fill date on each.
Collaborative Practice Agreements
Under a collaborative care agreement can the prescription be called in under the medical director for the clinic or should it be called in under the actual referring prescriber?
Collaborative practice agreements are specific to a physician’s own patients. If a pharmacist is operating under a collaborative practice agreement authorized by a physician, the pharmacist may only treat or issue prescriptions under that provider’s name for that provider’s specific patients. The prescription should be called in under the name of the prescriber who is issuing the prescription. It cannot be called in under the medical director’s name unless the medical director is treating the patient and has established a collaborative practice agreement with the pharmacist.
No. Currently, rules do not permit collaborative practice agreements with any other practitioners. The agreements are limited to physicians only.
Pharmacy Questions
General, Exemptions, Transfers, Care Facilities, Collaborative Practice, Emergency Service Programs, and Non-resident
The eRx mandate does not automatically nullify or void prescription transmitted by non- electronic methods. After the pharmacist fulfills his/her professional responsibility as it relates to prescription dispensing, the pharmacist may fill prescriptions transmitted verbally, via facsimile, or written on paper. The pharmacist may, in his/her professional judgement, report violations of the eRx mandate to the BOP or the prescriber’s professional licensing board.
What if a pharmacy calls back and doesn’t have a med or needs to change the prescription? Can they accept that change over the phone?
Yes, changes can be made over the phone. The original transmission is still valid and the pharmacy can electronically annotate the prescription in the system. Additionally, systems may have the capability to forward prescriptions to another pharmacy, reject a prescription back to the prescriber, and request changes.
It depends. The Code provides an exemption to electronic transmission for “a prescription requiring information that makes electronic transmission impractical, such as complicated or lengthy directions for use or attachments” and for “a prescription for a compounded preparation containing two or more components.” If the IV therapy falls into either of those two descriptions, the prescription would be exempt from the electronic transmission mandate. If the IV therapy is an FDA-approved, commercially available product, it would not likely meet those criteria for exemption.
No. The mandate to transmit electronically applies to “prescriptions.” Iowa Code 155A.3 provides separate definitions for “prescription drug orders” and “medication orders,” implying that the electronic mandate does not apply to “medication orders” in the hospital setting.
Iowa Code 155A.27 and 124.308 exempt prescriptions:
- For a patient residing in a nursing home, long-term care facility, correctional facility, or jail
- Authorized by a licensed veterinarian
- For devices
- Dispensed by a department of Veterans Affairs pharmacy
- Requiring information that makes electronic transmission impractical, such as complicated or lengthy directions for use or attachments
- For compounded preparations containing two or more components
- Issued in response to a public health emergency in a situation where a non-patient specific prescription would be permitted
- Issued for an opioid antagonist pursuant to Iowa Code section 135.190 or issued for epinephrine pursuant to Iowa Code section 135.185
- Issued during a temporary technical or electronic failure at the location of the prescriber or pharmacy, provided that the prescription indicates the temporary technical or electronic failure
- Issued pursuant to a collaborative practice agreement, standing order, drug research protocol
- Issued in an emergency situation
An emergency situation may include, but is not limited to, the issuance of a prescription to meet the immediate care need of a patient after hours when a prescriber is unable to access electronic prescribing capabilities. Such prescription shall be limited to a quantity sufficient to meet the acute need of the patient with no authorized refills.
It depends.
- When a pharmacy receives a CII-V prescription via electronic transmission and does not fill the prescription, the original prescription may be electronically forwarded to another pharmacy. The prescription may not be transferred via phone or fax like other transfers of refills.
- When a pharmacy receives a CII-V prescription via hard copy, fax, or phone and does not fill the prescription, the original prescription may not be transferred to another pharmacy. A hard copy prescription may be returned to the patient to take to another pharmacy of the patient’s choice. A prescription received via fax or phone may not be transferred and the prescriber will need to phone or fax a new prescription to the pharmacy of the patient’s choice.
No. Long-term-care and nursing home prescriptions are specifically exempted by Code and Board rules. Assisted living facilities and mental health group homes can be considered long-term-care for the purposes of this mandate.
Can a pharmacist who is practicing under a Collaborative Practice Agreement with a physician electronically transmit a prescription on behalf of the prescriber to be filled at another pharmacy?
Prescriptions issued pursuant to a CPA are exempt from the electronic transmission mandate, but are allowed to be transmitted electronically.
For a pharmacy-based service program, is the medical director required to electronically transmit prescriptions to the pharmacy to justify the use/replacement of controlled substances to the service program?
No. The prescriptions issued in response to the administration of a controlled substance by a service program would be exempt from the electronic prescribing mandate as an emergency situation. The prescription (or patient care record, if used) would still be required to have all the required elements when presented to the pharmacy.
It depends.
- If the prescriber is practicing in another state and is treating the patient in that state, the prescriber is not bound by Iowa law pertaining to electronic prescribing. If the patient then travels across state lines to fill the prescription in Iowa, the pharmacy may fill the prescription. Pharmacies may adopt their own policies on whether or not they will fill/honor prescriptions issued in a non-electronic format.
- If the prescriber is treating the patient while the patient is located in Iowa (telehealth, traveling provider), the provider must be licensed in the state of Iowa and is bound by the e-prescribing requirements.
If so, is it for prescriptions to Iowa patients or from Iowa doctors?
For the mandate to apply, the practice has to be subject to the jurisdiction of Iowa. So, both the prescriber and the pharmacy would need to be engaged in the practice in Iowa (including by telehealth). If one of them isn’t, the mandate cannot apply.
Patient Questions
Yes. The new law simply requires the prescriptions be transmitted electronically to the pharmacy, but a practitioner can still issue up to a 90 day supply of schedule II controlled substances as separate prescriptions to be filled at a future time.
A pharmacy’s computer system will be able to forward your prescription, including for controlled substances, to another pharmacy of your choosing.