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Pharmacist Licensure and Certification Requirements (1.5)

Pharmacist Licensure and Certification Requirements (1.5) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.5

POLICY & PROCEDURE





Effective Date:

September 2002

Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.5

Original
 Revision 6/16


Page 1
of 4

Title: Pharmacist Licensure and
Certification Requirements


I. PURPOSE: To establish departmental policy and procedures for new pharmacist employees
who are not licensed in Wisconsin. To verify the current registration status of registered
pharmacists employed at UWHC and to assure accurate record keeping of licensure information.
To establish departmental policy regarding certification of pharmacists.

II. POLICY: All pharmacists must be licensed and in good standing with the Pharmacy
Examining Board/Wisconsin Department of Regulation and Licensing within the timeframe
outlined below as well as keep their license up-to-date. Any pharmacist with 50% or more of
their FTE in any combination of direct patient care roles is to be certified and maintain an
accepted credential by the time frames outlined below.

III: PROCEDURE:
A. Licensure of Pharmacists
1. New pharmacists are encouraged to be licensed in Wisconsin before their start date,
whenever possible.
2. For new pharmacist employees not licensed in Wisconsin:
a. The pharmacist should refer to the Department of Regulation and
Licensing website for requirements, information, and steps that should be
followed in the Wisconsin licensure application process:
http://www.drl.state.wi.us/.
b. If the new pharmacist is licensed in another state, s/he must apply for
reciprocity with the Wisconsin Pharmacy Examining Board (PEB) and
can, according to Wis. Stats. §450.03(1)(g), practice pharmacy as a non-
credit intern provided all of the following are met: :
i. They are licensed as a pharmacist in another state
ii. They file an application for a pharmacist license in Wisconsin
pursuant to Wis. Stats. §450.05
iii. They work under the direct supervision of a person licensed as a
pharmacist by the board, and;
iv. They work during the period before which the board takes final
action on their application.
c. If the employee is NOT licensed in another state, s/he must apply for
original licensure with the Wisconsin PEB and supply to the board
evidence of having been graduated from a professional Bachelor of
Science degree in pharmacy or Doctor of Pharmacy degree granting
institution located in this or another state. S/he may then practice
pharmacy as a post-graduate intern as stated in Wis. Admin. Code §17.02.

POLICY & PROCEDURE





Effective Date:

September 2002

Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.5

Original
 Revision 6/16


Page 2
of 4

Title: Pharmacist Licensure and
Certification Requirements

d. The post-graduate intern can work under general supervision. The
supervising pharmacist does not need to have immediate on premises
availability to continually coordinate, direct and inspect at first hand
practice. Electronic routing of documentation and reporting of order
verification will be used.
i. Practicing as a post-graduate intern is limited to a total of 2000
hours.
ii. The supervising pharmacist must keep a written record of the hours
and location worked by you as an intern under his or her
supervision. Both you and your supervising pharmacist must sign
the written record. The written record shall be produced to the
board upon request.
e. Per department policy, all licensing exams/requirements must be
completed within 60 days after the employment start date.
f. Per department policy, employees must be licensed in Wisconsin within 90
days of their employment start date.
g. Incoming pharmacy residents must take licensure exams by August 1st. If
licensing by September 1st does not occur, a meeting between the resident,
resident program director, and director of pharmacy will occur to discuss
remedial action and may include dismissal from the program.
3. Verifying Active Licensure for New Professional Staff
a. The departmental secretary shall obtain for each new pharmacist a print out
of his/her Wisconsin pharmacist license status from the Wisconsin
Department of Regulation and Licensing web site.
b. The departmental secretary shall determine the posting location of the
original license. This information will be entered in the employee database
and a hardcopy printout will be kept on file in the pharmacy office.
c. All pharmacists licensing information will be entered and stored in a
human resource information system.
4. The pharmacist is responsible for displaying their current license in their place of
practice to comply with Administrative Code Phar 5.03.Audit of Active Licensure
for Existing Professional Staff
a. During June of each renewal year the department secretary will check each
pharmacist’s eligibility to practice against the State of Wisconsin
Department of Regulation and Licensing web site.
i. Information is entered into the department employee database.
ii. A hardcopy of this information is kept on file in the pharmacy office.

POLICY & PROCEDURE





Effective Date:

September 2002

Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.5

Original
 Revision 6/16


Page 3
of 4

Title: Pharmacist Licensure and
Certification Requirements

iii. This information will be entered and stored in a hospital human
resource information system.
iv. The pharmacist is responsible for displaying their license and current
renewal card in their place of practice to comply with Administrative
Code Phar 5.03.
b. Any problems identified will be referred to the appropriate manager for
resolution.
B. Certification of Pharmacists
1. Any pharmacist with 50% or more of their FTE in any combination of direct patient
care roles (any pharmacist working on/in an: inpatient clinical team at University
Hospital, AFCH, Rehab, or TAC; inpatient consult team; OR; infusion center;
decentral overnights; ambulatory, clinic or drug policy) is required to be certified.
2. Pharmacists with more than 50% of their FTE in other areas, including PRC, Unity,
meds management/ITS, central, central overnights and residents are excluded from
the certification requirement.
3. Board certification through the Board of Pharmacy Specialties (BPS) is the required
credential with two exemptions:
a. Ambulatory Teams 5 and 7 may be certified as a Certified Anticoagulation
Care Provider (CACP) through National Certification Board for
Anticoagulation Providers (NCBAP).
b. Ambulatory Teams 2 and 7 may be certified as a Certified Specialty
Pharmacist (CSP) through the Specialty Pharmacy Certification Board
(SPCB)
4. All currently employed pharmacists must be certified by the end of 2018
a. Current pharmacists in retail oncology and speciality areas are required to
be certified by the end of 2016
b. If initial examination is failed, the pharmacist will work with their manager
to be certified within 12 months of the failed exam.
5. If the initial licensing exam is failed:
a. The pharmacist must retake the failed test at the earliest available
opportunity.
b. Failure to pass on the next attempt may result in termination.
6. New pharmacist employees who are not certified and those who transfer from a
position where certification was not required to one where certification is required
must be certified within 18 months of becoming eligible.
7. Certification should be maintained continuously and pharmacists must become
certified within one year of any lapse in certification.
8. Not complying with this policy may result in termination.

POLICY & PROCEDURE





Effective Date:

September 2002

Chapter: Administrative
Operations Procedure Manual
Chapter:

Policy #: 1.5

Original
 Revision 6/16


Page 4
of 4

Title: Pharmacist Licensure and
Certification Requirements

9. Compensation for certification will be granted to pharmacists required to obtain
certification by this policy:
a. A meeting day will be granted based upon the date of the examination and
should be requested using the process outlined in policy 1.17. Up to three
meeting days will be allowed for attempts to pass the initial examination of
the initial examination is failed. No meeting days are given for
recertification exams.
b. As meeting days are not granted for weekends, if the examination occurs
on a weekend a different day will be granted in compensation.
c. To obtain reimbursement the pharmacist should provide to the
departmental secretary a receipt for the cost of the examination and
evidence the certificate was obtained.
d. The department will reimburse 100% of the cost of the initial examination.
e. Pharmacy residents who obtain certification during their residency year
can submit for reimbursement upon hire into a position requiring
certification per this policy.
f. Certified pharmacists will be eligible for up to $300 per year in
reimbursement for necessary continuing education and maintenance fees
required to maintain certification. Reimbursement will be provided after
successful completion of continuing education activities. Receipts from the
previous year must be provided by May 1st and payment will be batched.
10. Documentation and maintenance of certifications
a. The departmental secretary shall obtain for each new pharmacist the
currently held credential(s) and expiration date(s)
b. Each year at performance appraisal, certification information for current
employees will be updated with the pharmacist’s manager and forwarded
to the departmental secretary.
c. All pharmacist certification information will be entered and stored in a
human resource information system.

IV. COORDINATION
A. AUTHORED BY: Philip Trapskin, PharmD; David Hager, PharmD
COMMITTEE APPROVAL BY: Pharmacy Performance Improvement and Regulatory
Compliance (PPIRC), Department Managers





Approved By:_____________________________________
Director of Pharmacy

Date:_________
_