Rx Pads Guide By State

RX PAD GUIDE LINE BY STATE

STANDARD RX PADS What you need to know: - Are they looking for blue or green background? - 1 part pads or 2 part books? - Horizontal or vertical layout? - Which state will these be used in? - 1 part blue horizontal is our best seller! - Paper itself meets CMS guidelines before any imprint. - To be used for controlled substance scripts in most of the states. (Not to be used for controlled substance scripts in CA, DE, IN, KY, NJ, WA or WV) - Some states have additional requirements like certain statements, or signature lines that are needed to meet their regulations. (i.e. SC must have two signature lines, the left saying “Dispense As Written” and the right one saying “Substitution Permitted”) - There is no charge for batch numbering. - 1 part pads have an upcharge for consecutive numbering if not state mandated. All 2 part books have an upcharge for consecutive numbering, regardless if state mandated or not.

STANDARD RX PADS (cont.) CMS guidelines are the minimum security features that must be applied to all controlled substance scripts, put in place by the Federal government back in 2008. In the least, there must be one security feature from each category on the script.

Category 1 – One of more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form. - “Void” or “Illegal” pantograph - Reverse “Rx” or white area on prescription - Coin-reactive ink - Security back print - Watermarking (forderiner) - Diagonal lines (patented “VOID”) - Micro printing STANDARD RX PADS (cont.) Category 2 – One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber. - Uniform non-white background color - Quantity check off boxes - Refill Indicator (circle or check number of refills or “NR”) - Pre-print “Rx is void if more than ____ Rx’s on paper” on prescription paper - Quantity border and fill (for computer generated prescriptions on paper only) - Refill border and fill (for computer generated prescription on paper only) - Chemically reactive paper - Paper toner fuser - Safety or security paper with colored pattern

Category 3 – One or more industry-recognized features designed to prevent the use of counterfeit prescription forms - Security features and descriptions listed on prescriptions - Serial/Batch number - Encoding techniques (bar codes) - Logos - Metal stripe security - Heat sensing imprint - Invisible fluorescent fibers/ink - Thermochromic ink - Holograms that interfere with photocopying STANDARD RX PADS (cont.)

ITEM #’S: PRES-1BLH (1 part blue horizontal pad) PRES-1BLV (1 part blue vertical pad) PRES-1GNH (1 part green horizontal pad) PRES-1GNV (1 part green vertical pad) PRES-2BLH (2 part blue horizontal book) PRES-2BLV (2 part blue vertical book) PRES-2GNH (2 part green horizontal book) PRES-2GNV (2 part green vertical book) PRESLBL (8-1/2”x11” blue laser Rx full sheet) PRESLBLI (8-1/2”x11” blue laser Rx full sheet, imprinted) PRESLBL2 (8-1/2”x11” blue laser Rx half sheet, perfed at 5-1/2” from top) PRESLBL2I (8-1/2”x11” blue laser Rx half sheet, imprinted, perfed at 5-1/2” from top) PRESLBL4 (8-1/2”x11” blue laser Rx quarter sheet, perfed at 4” from left & 5-1/2” from top) PRESLBL4I (8-1/2”x11” blue laser Rx quarter sheet, imprinted, perfed at 4” from left & 5-1/2” from top) STANDARD RX PADS (cont.)

ITEM #’S: PRESLGN (8-1/2”x11” green laser Rx full sheet) PRESLGNI (8-1/2”x11” green laser Rx full sheet, imprinted) PRESLGN2 (8-1/2”x11” green laser Rx half sheet, perfed at 5-1/2” from top) PRESLGN2I (8-1/2”x11” green laser Rx half sheet, imprinted, perfed at 5-1/2” from top) PRESLGN4 (8-1/2”x11” green laser Rx quarter sheet, perfed at 4” from left and 5-1/2” from top) PRESLGN4I (8-1/2”x11” green laser Rx quarter sheet, imprinted, perfed at 4” from left & 5-1/2” from top) PRESBLHLBL (8-1/2”x11” blue laser Rx sheet, 5-1/2”x4-1/4” script in upper left corner, perfed) PRES-THERMBL (thermal Rx rolls, blue background, 4-5/16” (w) x 6” (h) script with timing mark, batch # on back in center) PRES-THERMBLFUR (thermal Rx rolls, blue background, 4-5/16” (w) x 6” (h) script with timing mark, batch # on front in upper right hand corner) STANDARD RX PADS (cont.)

What you need to know: - Wilmer approved to print through the state. - CA Health and Safety Code 11162.1 for controlled substances. - Know if they want 1 part or 2 part scripts. (our offering is limited to the blue horizontal) - Gather the physician’s name, category of licensure, license #, DEA # and address to be imprinted. - We must verify the physicians name, LIC# and DEA# on each and every order. - Can only ship to the address listed on their LIC# or DEA#. - Each order must have a batch, consecutive, serial# and barcode on the script, we will create this. (at no charge) - Laser Rx sheets: we must imprint all of the doctors information on the script, regardless if their software can do it or not per state regulations. - Facilities can use a designated prescriber to ship orders to. They are responsible for recording which physician has the scripts (by number) and their info must be pre-printed on the script. - All order information needs to be retained for 3 years in case of audit. BLUE BACKGROUND. REFLECTIVE WATERMARK ON BACK. SP 98 FAMILY PRACTICE CENTER Physician Name, M.D. 123 Address Way City, ST 12345 123-456-1234 DEA# XX1234567 Lic: X12345 Physician Name, M.D. 123 Address Way City, ST 12345 123-456-1234 DEA# XX1234567 Lic: X12345 000001 19301102214 BLUE BACKGROUND. REFLECTIVEWATERMARK ON BACK. 000001 19301102214 Serial # WCZ289A00001 FAMILY PRACTICE CENTER Physician Name, M.D. 123 Address Way City, ST 12345 123-456-1234 DEA# XX1234567 Lic: X12345 Physician Name, M.D. 123 Address Way City, ST 12345 123-456-1234 DEA# XX1234567 Lic: X12345 BLUE BACKGROUND. REFLECTIVEWATERMARK ON BACK. SP 98 State License # X00000 Institution Name 123 Institution Way Any Town, U.S.A. 12345 Dr. Prescriber Name, DEA # XX0000000, State License # X00000 Prescriber Name & Category of Licensure DEA Number State License Number Telephone Number Designated Prescriber: 000001 19301102214 CALIFORNIA Rx pads

Health and Safety Code 11162.1 https://oag.ca.gov/sites/all/files/agweb/pdfs/securityprinters/hsc11162-1.pdf? Guidelines for Security Printer Policies and Procedures https://oag.ca.gov/sites/all/files/agweb/pdfs/securityprinters/Guidelines_for_Security_Printer_20120214.pdf? ITEM #’S: PRES-CA1BL (1 part blue horizontal single prescription allowed on script) PRES-CA1BLI (1 part blue horizontal single prescription allowed on script, institutional style) PRES-CA1BLM (1 part blue horizontal multiple prescriptions allowed on script) up to 3 PRES-CA1BLMI (1 part blue horizontal multiple prescriptions allowed on script, Institutional style) up to 3 PRES-CA1BLANK (1 part blue horizontal, blank background to match other vendors design) PRES-CA2BL (2 part blue horizontal single prescription allowed on script) PRES-CA2BLI (2 part blue horizontal single prescription allowed on script, institutional style) PRES-CA2BLM (2 part blue horizontal multiple prescriptions allowed on script) up to 3 PRES-CA2BLMI (2 part blue horizontal multiple prescriptions allowed on script, institutional style) up to 3 PRES-CA2BLANK (2 part blue horizontal, blank background to match other vendors design) CALIFORNIA RX PADS (cont.)

LASER RX SHEETS: PRESCALBLI (8-1/2”x11” blue laser Rx sheet, imprinted, 5-1/2x4-1/4 script in upper left corner, perfed) PRESCABLBLI (8-1/2”x11” blue laser Rx sheet, imprinted, 5-1/2x4-1/4 script in bottom left corner, perfed) PRESCASHLBLI (8-1/2”x11” blue laser Rx sheet, full sheet, imprinted) CALIFORNIA ITEM #’s (cont.)

What you need to know: - Wilmer approved to print through the state. - Title 16, Section 4797 of the Delaware Code for all prescriptions (controlled and non-controlled) - You need to apply to get approval to sell the scripts through the state, and access to the website for looking up physician information. ($250 fee) - Know if they want 1 part or 2 part, horizontal or vertical (our offering is limited to blue background only) - Security code must be received from the physician and you must verify through the Delaware database. This must also be passed to us for us to verify. - Must ship to the address approved by the Division of Professional Regulation. - Cannot ship to a residential address unless the physician’s office/business are attached. - Must be consecutively numbered (no upcharge on 1 part) - All order information needs to be retained for 5 years in case of audit. DELAWARE RX PADS

Title 16, Section 4797 of the Delaware Code http://regulations.delaware.gov/AdminCode/title24/prescription.shtml ITEM #’S: PRES-DE1BLH (1 part blue horizontal numbered pad) PRES-DE1BLV (1 part blue vertical numbered pad) PRES-DE2BLHNO (2 part blue horizontal numbered book) PRES-DE2BLVNO (2 part blue vertical numbered book) PRESDELBL (8-1/2”x11” blue laser Rx full sheet) PRESDELBLI (8-1/2”x11” blue laser Rx full sheet, imprinted) PRESDELBL2 (8-1/2”x11” blue laser Rx half sheet, perfed at 5-1/2” from top) PRESDELBL2I (8-1/2”x11” blue laser Rx half sheet, imprinted, perfed at 5-1/2” from top) PRESDELBL4 (8-1/2”x11” blue laser Rx quarter sheet, perfed at 4” from left & 5-1/2” from top) PRESDELBL4I (8-1/2”x11” blue laser Rx quarter sheet, imprinted, perfed at 4” from left & 5-1/2” from top) DELAWARE RX PADS (cont.)

What you need to know: - Wilmer approved to print through the Florida Medicaid agency and the state. - FL rule 64B-3.005 for controlled substances. - HB21 update to controlled substances. - You must gather the physician or hospital’s name, address and category of licensure and space for DEA # to be imprinted on pads. - Physician or hospital’s license # must be provided to verify. - Know if they want 1 part or 2 part, horizontal or vertical, blue or green background. - Requires unique batch numbering. (no upcharge) - Must have checkboxes for ACUTE PAIN EXCEPTION and NONACUTE PAIN (preprinted or handwritten) - Must ship to the address on record of the doctor or healthcare facility. - Orders must be received in writing from the physician or hospital and kept on file for three years. FLORIDA RX PADS

Florida Administrative Code 64B-3.005 https://www.flrules.org/Gateway/View_notice.asp?id=5762496 HB21 Rule https://www.flhealthsource.gov/FloridaTakeControl/ Medicaid Agency section 409.912 (8)(a)(5) of the Florida Statute http://www.fdhc.state.fl.us/medicaid/prescribed_drug/prescription_pad.shtml ITEM #’S: PRES-1BLH (1 part blue horizontal pad) PRES-1BLV (1 part blue vertical pad) PRES-1GNH (1 part green horizontal pad) PRES-1GNV (1 part green vertical pad) PRES-2BLH (2 part blue horizontal book) PRES-2BLV (2 part blue vertical book) PRES-2GNH (2 part green horizontal book) PRES-2GNV (2 part green vertical book) PRESLBLI (8-1/2”x11” blue laser Rx full sheet, imprinted) PRESLBL2I (8-1/2”x11” blue laser Rx half sheet, imprinted, perfed at 5-1/2” from top) PRESLBL4I (8-1/2”x11” blue laser Rx quarter sheet, imprinted, perfed at 4” from left and 5-1/2” from top) PRESLGNI (8-1/2”x11” green laser Rx full sheet, imprinted) PRESLGN2I (8-1/2”x11” green laser Rx half sheet, imprinted, perfed at 5-1/2” from top) PRESLGN4I (8-1/2”x11” green laser Rx quarter sheet, imprinted, perfed at 4” from left & 5-1/2” from top) FLORIDA RX PADS (cont.)

What you need to know: - Wilmer approved to print through the state. - IN guidelines for controlled substances 856 IAC 1-34 - All scripts must look exactly like the IN regulations. - Do they want 1 part or 2 part (offering is limited to blue horizontal due to regulations) - The physician’s name, address, LIC# and DEA# must be preprinted, stamped or manually printed on the script. - DEA # can be imprinted with DEA#______ to be written in when prescribing. - Only one prescription can be written per blank. - Logo’s can only be placed in upper left hand corner. INDIANA RX PADS - 856 IAC 1-34 http://www.in.gov/pla/files/856_IAC_134(3).pdf - IN template http://www.in.gov/pla/files/Security_Feature_Prescription _Paper_Template(7).pdf

ITEM #’S: PRES-IN1BL (1 part blue horizontal pad, single prescription allowed on script) PRES-IN2BL (2 part blue horizontal book, single prescription allowed on script) PRESINLBL (8-1/2”x11” blue laser Rx sheet, 5-1/2”x4-1/4” script in upper left corner, perfed) PRESINLBLI (8-1/2”x11” blue laser Rx sheet imprinted, 5-1/2”x4-1/4” script in upper left corner, perfed) INDIANA RX PADS (cont.)

What you need to know: - Wilmer approved to print by the state. - Kentucky regulations 902 KAR 55:105 for controlled substances and Medicaid scripts. - Know if they want 1 part or 2 part scripts. (offering is limited to horizontal pantone green due to regulations) - Logo must go in upper left hand corner. - The physician’s name, address and phone number must be preprinted, stamped or manually printed on the script. - DEA # can be imprinted with DEA#______ to be written in when prescribing. - One prescription can be written per script. - Orders must ship to the address listed on the DEA# - Orders must be received in writing from the physician or hospital and kept on file for two years. KENTUCKY RX PADS

KY regulations 902 KAR 55:105 http://www.lrc.state.ky.us/kar/902/055/105.htm ITEM #’S: PRES-KY1GN (1 part pantone green horizontal pad) PRES-KY2GN (2 part pantone green horizontal book) PRESKYLGN (8-1/2”x11” pantone green laser Rx sheet, 5-1/2”x4-1/4” script in upper left corner, perfed) PRESKYLGNI (8-1/2”x11” pantone green laser Rx sheet imprinted, 5-1/2”x4-1/4” script in upper left corner, perfed) KENTUCKY RX PADS (cont.)

What you need to know: - Wilmer approved to print by the state. - Maine regulations 16-230 Chapter 1 for controlled substances. - Are they looking for blue or green background? - 1 part pads or 2 part books? - Horizontal or vertical layout? - The physician’s name, address and phone number must be preprinted, stamped or manually printed on the script. - DEA # can be imprinted with DEA#______ to be written in when prescribing. - One prescription can be written per script. - Orders must be received in writing from the physician or hospital and kept on file for two years. MAINE RX PADS

What you need to know: - Wilmer approved to print by the state. - You must also get approval to sell NJ scripts by filling out the subcontractor form. - New Jersey Administrative Code 13:45A-27 - Know if they want 1 part or 2 part scripts. (offering is limited to the green vertical due to regulations) - Know if they are ordering the Medical Doctor, Midwife, Physician’s Assistant, Optometrist, Eyewear (for lens prescriptions), Advanced Practice Nurse or the Healthcare Facilities scripts. - You must gather the physician or facilities, name, address, LIC#, NPI# and DEA# on each and every order. - Can only ship to the address listed with the NJPB board. - Rx’s for Physician’s Assistants, Midwives and Advanced Practice Nurses should be imprinted with the name and LIC# of the prescriber and his/her collaborating physician only. NEW JERSEY RX PADS

- Other scripts may have multiple names, but the font size cannot be smaller than 7pt font. - If printing multiple names on a script, any addition or deletion of a prescriber requires new scripts to be used within 30 days of this change. Or if adding a new prescriber, they can have their own script pads until time of reorder. - If imprinting multiple names, the purchase order must have listed a designated prescriber to receive the shipment. - Only one controlled substance can be written per script. - Scripts can be printed without the physician’s name, address, NPI# or facility # if they use an electronic records system. We must document that they use an EHR by recording the name and manufacturer of the EHR system on form created by NJPB. - Orders must be received in writing with signatures from each of the physicians or hospital and kept on file for five years. - There can be no online ordering, due to regulations. - LIC#’s of each physician on the script must be verified through the NJPB database on each and every order. - Minimum order must be at least 500 scripts (per NJPB guidelines). NEW JERSEY RX PADS (cont.)

New Jersey Administrative Code 13:45A-27 http://www.njconsumeraffairs.gov/regulations/Chapter-45A-Subchapter-27-UniformPrescription-Blanks.pdf ITEM #’S: PRES-NJ1APNV (1 part green vertical pad for Advanced Practice Nurses) PRES-NJ1EYEV (1 part green vertical pad for Eyewear) PRES-NJ1HCFV (1 part green vertical pad for Healthcare Facilities) PRES-NJ1MDV (1 part green vertical pad for Medical Doctors) PRES-NJ1MWV (1 part green vertical pad for Midwives) PRES-NJ1OPTV (1 part green vertical pad for Optometrists) PRES-NJ1PAV (1 part green vertical pad for Physician’s Assistants) PRES-NJ2APNV (2 part green vertical pad for Advanced Practice Nurses) PRES-NJ2EYEV (2 part green vertical pad for Eyewear) PRES-NJ2HCFV (2 part green vertical pad for Healthcare Facilities) PRES-NJ2MDV (2 part green vertical pad for Medical Doctors) PRES-NJ2MWV (2 part green vertical pad for Midwives) PRES-NJ2OPTV (2 part green vertical pad for Optometrists) PRES-NJ2PAV (2 part green vertical pad for Physician’s Assistants) NEW JERSEY RX PADS (cont.)

PRESNJAPNLGNI (8-1/2”x11” green laser Rx for Advanced Practice Nurses, imprinted, 4-1/4”x51/2” script in upper left corner, perfed) PRESNJEYELGNI (8-1/2”x11” green laser Rx for Eyewear, imprinted, 4-1/4”x5-1/2” script in upper left corner, perfed) PRESNJHCFLGNI (8-1/2”x11” green laser Rx for Healthcare Facilities, imprinted, 4-1/4”x5-1/2” script in upper left corner, perfed) PRESNJMDLGNI (8-1/2”x11” green laser Rx for Medical Doctors, imprinted, 4-1/4”x5-1/2” script in upper left corner, perfed) PRESNJMWLGNI (8-1/2”x11” green laser Rx for Midwives, imprinted, 4-1/4”x5-1/2” script in upper left corner, perfed) PRESNJOPTVLGNI (8-1/2”x11” green laser Rx for Optometrists, imprinted, 4-1/4”x5-1/2” script in upper left corner, perfed) PRESNJPAVLGNI (8-1/2”x11” green laser Rx for Physician’s Asssistants, imprinted, 4-1/4”x5-1/2” script in upper left corner, perfed) NEW JERSEY RX PADS (cont.)

What you need to know: - Wilmer approved to print by the state. - Washington’s regulations RCW 18.64.500 for all prescriptions (controlled and non-controlled) - The physician’s name, address, DEA# can be imprinted or added at the time of prescribing. - New regulations have changed the seal of approval. There is no longer green thermochromic ink, and the wording has changed. Old scripts are still valid, however. - 1 part pads or 2 part books - Horizontal or vertical layout Washington regulation http://app.leg.wa.gov/rcw/default.aspx?cite=18.64.500 ITEM #’S: PRES-WA1BLH (1 part blue horizontal pad) PRES-WA1BLV (1 part blue vertical pad) PRES-WA2BLH (2 part blue horizontal book) PRES-WA2BLV (2 part blue vertical book) PRESWALBL (8-1/2”x11” blue laser Rx sheet) PRESWALBL2 (8-1/2”x11” blue laser Rx sheet, perfed at 5-1/2” from top) PRESWALBL4 (8-1/2”x11” blue laser Rx sheet perfed at 4” from left and 5-1/2” from top) WASHINGTON RX PADS

What you need to know: - West Virginia Code 60A-9-4 for controlled substances. - West Virginia Code 64-9-1 - The name, address, phone #, DEA# and NPI# should be imprinted, stamped or handwritten on the script. - 1 part pads or 2 part books (our offering is limited to the screen horizontal due to regulations) WV code 60A-9-4 http://www.legis.state.wv.us/WVCODE/ChapterEntire.cfm? chap=60a&art=9&section=4#09 WV code 64-9-1 http://law.justia.com/codes/westvirginia/2011/chapter64/article9/64-9-1 ITEM #’S: PRES-WV1GN (1 part green horizontal pad) PRES-WV2GN (2 part green horizontal pad) WEST VIRGINIA RX PADS

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