Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 95 - PHARMACISTS AND PHARMACIES › Subchapter 16 - EMERGENCY CONTRACEPTION COLLABORATIVE AGREEMENT › Exhibit A - Emergency Contraception Drug Therapy Collaborative Agreement

Current through June, 2024
As a licensed physician authorized to prescribe medications
				  in the State of Hawaii, I authorize the licensed pharmacist
				  _________________________________ to initiate emergency contraception drug
				  therapy according to the terms and conditions that follows and according to
				  Hawaii Administrative Rule §
									16-95-130. This Agreement provides
				  written terms and conditions for initiating emergency contraception drug
				  therapy in accordance with the laws and rules of the State of Hawaii. This
				  agreement shall be delivered to the Department of Commerce and Consumer Affairs
				  within seven (7) days of the execution of the agreement by the licensed
				  pharmacist and the licensed physician. Any modification to an existing
				  collaborative agreement previously delivered to the Department shall be
				  delivered also to the Department by the licensed pharmacist at least ten
				  working days prior to the intended implementation of the changed collaborative
				  agreement.
Purpose:
Permit the use of drug therapy within
				  120 hours of the patient having unprotected sexual contact and to ensure the
				  patient receives adequate information to successfully complete drug
				  therapy.
Procedures:
When the patient's pharmacist
				  requests drug therapy, the pharmacist shall assess the need for drug therapy
				  and/or referral for contraceptive care and reproductive health care. The
				  pharmacist shall determine the following:
1. The date of the patient's last menstrual
				period to rule out established pregnancy;
2. Whether the elapsed time since unprotected
				intercourse is less than 120 hours;
3. Whether the patient has been a victim of
				sexual assault; and
4. That the
				patient is at least 14 years of age.
Referrals:
The licensed pharmacist shall
				  refer the patient to the licensed physician for follow-up. If drug therapy
				  services are not available at the pharmacy, the pharmacist shall refer the
				  patient to another licensed pharmacist. Also, the pharmacist shall refer the
				  patient to see either a medical doctor or family planning clinic provider
				  if:
A. The pharmacist cannot rule out
				that the patient is pregnant or if the elapsed time since the patient having
				unprotected intercourse is greater than 120 hours;
B. The pharmacist is concerned that the
				patient may have been exposed to a sexually transmitted disease;
C. The patient does not have a regular
				contraceptive method; and
D. The
				patient does not have a health care provider and needs free or low cost family
				planning services.
This Emergency Contraception Drug Therapy collaborative
				  Agreement was developed using the collaborative agreements of Washington and
				  California, who developed their guidelines from the American College of
				  Obstetricians and Gynecologists and the World Health Organization and
				  physicians, pharmacists and nurses. This Agreement has been approved by the
				  Board of Pharmacy, State of Hawaii.
If the pharmacist is concerned that the patient may have
				  contracted a sexually transmitted disease through unprotected sexual activity
				  and/or if the patient indicates that she has been sexually assaulted, the
				  pharmacist may recommend referral to a medical doctor, a family planning
				  clinic, a sexual assault treatment center, the police, or multiple referrals to
				  these entities as the pharmacist may deem appropriate, while providing drug
				  therapy.
While drug therapy can be used repeatedly without serious
				  health risks, patients who request drug therapy shall be referred to a medical
				  doctor or family planning clinic provider for consideration of the use of a
				  regular contraceptive method.
Drug Therapy product selection:
The
				  pharmacist shall provide medication from a list of drugs approved for emergency
				  contraception by the United States Food and Drug Administration ("FDA") listed
				  in Exhibit "B" and agreed upon as part of this collaborative Agreement. Plan
				  B® shall be the preferred drug therapy. The list shall include emergency
				  contraceptives and adjunctive medications for treatment of nausea and vomiting
				  associated with emergency contraceptives. The list shall be maintained at the
				  pharmacy and shared by all participants in the agreement. Along with the
				  medication, the pharmacist shall provide drug information concerning dosage,
				  potential adverse effects, and follow-up contraceptive care.
Prescription labeling:
The label placed on
				  the drug therapy product shall contain the names of both the pharmacist and the
				  physician signers of this Agreement.
Documentation:
Each drug therapy
				  prescription authorized by the physician and initiated by the pharmacist shall
				  be documented in a patient profile.
Training:
The pharmacist who participates in the
				  drug therapy shall have received appropriate training that includes programs
				  approved by the American Council of Pharmaceutical Education (ACPE),
				  curriculum-based programs from an ACPE-accredited college of pharmacy, state or
				  local health department programs, or programs recognized by the board of
				  pharmacy. Training must include procedures listed above, the management of the
				  sensitive communications often encountered in emergency contraception, service
				  to minors, quality assurance, referral for additional services, documentation
				  and a crisis plan if the pharmacy operations are disrupted by individuals
				  opposing the emergency contraception.
Further, the pharmacist agrees to participate in the
				  Emergency Contraception Hotline.
Term of the Agreement:
This agreement shall be
				  effective for a period of at least two years from the date of its delivery to
				  the Department unless rescinded in writing earlier by either the physician or
				  the pharmacist, with written notice to the other and to the Department, or
				  unless the Pharmacy Board invalidates such Agreement or changes the terms of
				  the agreement. After the two year period, the agreement shall continue to be
				  valid month to month unless rescinded, invalidated, or changed as provided
				  herein. The licensed pharmacist or the licensed physician, who rescinds the
				  agreement, shall notify the Department within three business days of the
				  rescission. At the time the collaborative agreement is rescinded, the licensed
				  pharmacist shall not have prescriptive authority to dispense emergency
				  contraceptives until another collaborative agreement with a physician is
				  completed and delivered to the Department.
(Name of Pharmacy)
Informed Consent for Emergency Contraception Drug
				  Therapy
Name of Patient:______________________________________
				  Age:______________
Address:_____________________________________________
Phone No.:___________________________________________
First day of last menstrual period: __/ __/_____
Mo/Day/Year
Date of unprotected sexual intercourse: __/ __/ _____
Mo/Day/Year
If more than one exposure, give date and time of
				  initial exposure:
___________________________
Was this sexual intercourse the result of sexual assault?
				  Yes___ No___
Before giving your consent, be sure that you understand both
				  the pros and cons of Emergency Contraceptive Pills (ECPs). If you have any
				  questions, we will be happy to discuss them with you. Do not sign your name at
				  the end of this form until you have read and understood each statement and the
				  pharmacist has answered your questions and can witness your signature. This
				  information is confidential.