OKLAHOMA

State Board of Pharmacy

2920 N Lincoln Blvd, Suite A Oklahoma City, OK 73105
pharmacy@pharmacy.ok.gov www.pharmacy.ok.gov
John A. Foust, Pharm.D., D.Ph., Executive Director
Phone: 405.521.3815 Fax: 405.521.3758

REQUEST FOR PILOT PROGRAM STATUS

Date _________________________
Pharmacy name
Address

(Please type or print legibly)

_________________________
_________________________
_________________________
_________________________

Email address
_________________________
OK Pharmacy License # _________________________
D.Ph. In Charge
_________________________
Non-Resident License # _________________________

(so we may contact you)

(name and Oklahoma license #)

(if applicable)

I request Oklahoma State Board of Pharmacy approval of a pilot program for the pharmacy listed above to ship or deliver patient
specific filled prescriptions to: (check all that apply)
_____

Prescriber office for administration due to the sterile medications special storage conditions (refrigerated or frozen).

_____

Prescriber clinic for administration due to the sterile medications special storage conditions (refrigerated or frozen).

_____

Prescriber office for patient pick-up due to the patients fragile mailing address.

_____

Prescriber clinic for patient pick-up due to the patients fragile mailing address.

_____

Other (Please attach an explanation of the need for your product to be shipped to the physician.)

Requirements of the pharmacy and pharmacist-in-charge:

1.
2.
3.

4.
5.
6.

7.
8.
9.

Documentation of a written request by the patient for delivery of the medication to the prescribers address.
Documentation of a written acceptance by the prescriber to accept the prescription.
Written policies and procedures will include but are not be limited to the following:
a. Method by which the pharmacy will document:
i. Patients name
ii. Prescription number and medication that is involved
iii. Shipping or mailing or delivery address and tracking information of delivery
The pharmacy is required to provide the prescribers office information on the medication storage requirements, including
Beyond Use Date information.
The pharmacy shall maintain a list of all medications involved in this pilot program for 2 years for review by the Board.
The pharmacy shall maintain a log of reported problems for 2 years, including documentation of how the problems were
addressed. This list must include, but is not limited to, lost shipments, returned shipments, dispensing and/or
compounding errors, how these issues are addressed.
All sterile compounded drugs must be compounded under current USP<797> and referenced chapter requirements as
mandated by state and federal law.
All non-sterile compounded drugs must be compounded under current USP<795> and referenced chapter requirements
as mandated by state and federal law.
Each year, a written report explaining how this pilot program is benefitting patients, including any issues or problems
associated with this pilot program, is required to be sent to the Board. The pharmacy must notify the Board in writing if the
pilot program is discontinued.

______________________________________________________
(signature of pharmacist-in-charge licensed in Oklahoma)
All non-resident pharmacies must have an Oklahoma licensed pharmacist acting as pharmacist-in-charge for their Oklahoma license.
Fragile address is defined as a current mailing address that is not secure and the patient is unable to receive any other mail-order
prescriptions at the address OR a patient who does not have a permanent mailing address.

A Constitutional Board Established in 1907

President
Jim Spoon, D.Ph.
Sand Springs

Vice-President
Justin Wilson, D.Ph.
Norman

Member
Greg Adams, D.Ph.
Clinton

Member
Kyle Whitehead, D.Ph.
Enid

Member
Mark St. Cyr, D.Ph.
Jones

Public Member
Stephen Dudley
Edmond