Iowa Prescription Monitoring Program

Pharmacy Request for Exemption from Reporting Controlled Substances and Naloxone Prescriptions

Iowa Board of Pharmacy
6200 Park Ave., Ste. 100
Des Moines, IA 50321
515-281-5944, Option 3

Pharmacy Name

Phone Number

Iowa Pharmacy License #

DEA Registration #

Iowa Code section 124.552 requires that each pharmacy that dispenses a controlled substance listed in Schedules II, III, IV or V of the Controlled Substances Act to a patient located in Iowa, and each pharmacy located in Iowa that dispenses a controlled substance to a patient located inside or outside Iowa, must submit a record of the dispensed prescription to the Iowa Prescription Monitoring Program (PMP) unless the pharmacy is specifically exempted from such reporting by Iowa Code or rule.

The pharmacy identified above requests exemption from the requirements for reporting to the Iowa PMP prescriptions for controlled substances dispensed to Iowa patients.

This exemption DOES NOT apply to the mandatory reporting of opioid antagonists (e.g., Narcan®) or non-prescription codeine containing Schedule V sales (e.g., Robitussin AC®).

The pharmacy claims exemption based on the following statement(s): (check all that apply)

Pharmacy does not dispense prescriptions or non-prescriptions for controlled substances or opioid antagonists (e.g., Narcan®) to patients located in Iowa.

Pharmacy dispenses controlled substances only to patients enrolled in a program registered by the US Drug Enforcement Administration (DEA) as a narcotic treatment program that is subject to the record keeping provisions of 21 CFR 1304.24.

Pharmacy dispenses controlled substances only to inpatients in a long-term care facility. Exemption does not apply to a patient in an assisted living facility or group home if medication management services are provided.

Pharmacy dispenses controlled substances only to inpatients in a hospice facility. This exemption does not apply to a home hospice patient or to a hospice patient in an assisted living facility or group home.

Pharmacy dispenses controlled substances only for administration to inpatients in a hospital. This exemption does not apply to controlled substances dispensed to outpatients or to ambulatory patients except as specifically identified herein and does not apply to controlled substances dispensed to hospital employees or other affiliates under the "own use" provisions of federal law.

A pharmacy that has been granted exemption from reporting to the Iowa PMP shall not be required to submit “zero reports” and shall not be deemed in violation of Iowa Code or rules for failure to submit a “zero report” during any period that the pharmacy continues to qualify for exemption from reporting to the Iowa PMP.

If the practice of a pharmacy that has been granted exemption from reporting to the Iowa PMP changes and the basis for the exemption is no longer valid, the pharmacy shall immediately notify the Iowa PMP administrator and shall immediately initiate reporting of qualified prescription information to the Iowa PMP. Notification to the Iowa PMP administrator shall be in writing and shall be delivered via email, fax, or other hard-copy delivery.

Signature of Pharmacist in Charge

First Name

Last Name

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I hereby certify, as the pharmacist in charge of the pharmacy identified above, that the exemption(s) claimed herein reflect the true and accurate practices of this pharmacy. I hereby agree that if the basis for exemption of this pharmacy from reporting to the Iowa PMP changes, I or any successor pharmacist in charge of this pharmacy shall immediately notify the Iowa PMP administrator and shall immediately initiate reporting of qualified prescription information to the Iowa PMP.