PROTOCOL CHECKLIST

Drug Therapy Management Protocol Checklist

The following provisions are required to be in any protocol that is approved by the Boards of Physicians and Pharmacy. This is only a list of provisions required by law, therefore your protocol will probably require more provisions than are listed below. You may also provide any supporting documentation that will help the Boards and the Drug Therapy Management Joint Committee in their review of your protocol.

The condition to be managed;
A list of medications that may be used under the auspices of the protocol;
Monitoring parameters including laboratory tests for the:
- Condition; and
- Medication employed;
A list of circumstances requiring pharmacist contact with the physician or physicians who are a party to the physician-pharmacist agreement;
A statement prohibiting substitution of a chemically dissimilar drug product by the pharmacist for the product prescribed by the physician unless permitted in the therapy management contract;
A list of circumstances under which the pharmacist may alter doses, modify the treatment regimen, or switch the agent under the terms of the therapy management contract;
Information to be documented;
A listing of provisions within the protocol that may be customized within a therapy management contract;
An action plan for situations when the pharmacist encounters a situation that is not addressed in the protocol;
A description of technical modifications that may be made to the protocol without submitting a request for amendment to the Boards.

PLEASE NOTE:

A protocol may authorize:
1. The modification, continuation, and discontinuation of drug therapy;
2. The ordering of laboratory tests; and
3. Other patient care management measures related to monitoring or improving the outcomes of drug or device therapy.
A protocol may not authorize acts that exceed the scope of practice of the parties to the physician-pharmacist agreement.
Technical modifications to the protocol shall be registered with the Board of Pharmacy within 30 days of the technical modification.
Any type of technical modification that will be allowed must be described in the approved protocol, otherwise the parties acting pursuant to the protocol will have to request approval of an amendment from the Boards.