PSYCHIATRIC MEDICATION THERAPY SERVICES (MTS)
Physician/Clinical Pharmacist Collaborative Agreement
____________________, Missouri
I.
Purpose: The purpose of this Agreement is to serve as a delegation of specific
roles, functions, and authority by and between the physician and the clinical
pharmacist as delineated herein. The specific function of this clinical
pharmacy service is for delineating and authorizing psychiatric medication
therapy services (MTS) provided to patients/clients seen at (Pharmacy or
clinical pharmacist practice location) referred by the physician(s) agreeing to
the terms of this collaboration and its purposes, and proper execution of this
Agreement.
II.
Functions: Upon physician referral, the clinical pharmacist will conduct
mental health assessments with an emphasis on pharmacotherapy, physical
and psychological routine tests and status reports as agreed upon by the
physician and provide services based upon the following situations:
 Patients with mood disorders and other mental health illnesses will be seen
routinely as part of a wellness assessment and quality of life program
described in a written mental health and injury protection procedure
manual located at the pharmacists permanent practice location and agreed
upon by the patient’s physician and pharmacist and reviewed and
approved by both health professionals, signed and dated personally at least
annually. All psychological and physical evaluations by the pharmacist
will occur through the authorization of the physician (psychiatrist) or a
physician-designated licensed clinical psychologist. After completion of
the initiation evaluation process, the authorizing physician may refer a
patient for continuing evaluation and follow-up care with the clinical
pharmacist. All physician referrals must be documented and include the
patient’s name, address, date of birth, and the date of referral.
 The pharmacist may provide on-going psychiatric assessments and
medication therapy recommendations/changes for a time period not to
exceed one-year. The pharmacist will discuss medication changes with
the physician during monthly treatment team meetings.
 Documentation of clinical pharmacy service must occur within 24 hours of
the patient encounter and will be provided to the authorizing physician for
review.
 The authorizing physician must have access to all clinical pharmacist
progress notes within 24 hours of the patient encounter. The pharmacist
and physician may meet in person at any time to discuss medication
therapy decisions.
 Clinical Pharmacy Progress Notes must be completed either on a (Name
of Pharmacy or Clinical Pharmacist Practice Location) prescriber note to
be placed in the patient chart located at (Name of Pharmacy or Pharmacy
Practice and Address) or electronically as a prescriber note and maintained
electronically in appropriate and agreed-upon electronic systems.
Physician/Pharmacist Protocol – Psychiatric Medication Therapy Services (MTS)
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III.
i. Prescriber- Clinical Pharmacist Progress Notes must include the
following information:
Patient name, date of birth, address, telephone number, pertinent
assessments, diagnostic testing performed, the name, strength,
dose, dosage schedule or route of administration of any medication
modified, referrals to authorizing physician or for emergency care,
any consultation with other treatment providers.
The authorizing physician must be notified immediately, in person or via
telephone, if a patient experiences a life-threatening allergic reaction,
overdose or suicide confirmed ideation or reported attempt, or if acute
hospitalization is necessary for psychiatric symptom control.
The clinical pharmacist may NOT delegate MTS responsibilities. At any
time during the course of clinical pharmacy MT services, the authorizing
physician may override, rescind, or modify the treatment protocol and
procedures being followed by the clinical pharmacist.
Delegation: upon referral to the clinical pharmacist, the referring physician
delegates the following authority:
 Psychiatric assessments with limited physical examination of patients with
the following Axis I or II diagnoses receiving treatment at (Name of
Pharmacy or Clinical Pharmacist Name and Place of Practice):
i. Alcohol-use disorders, amphetamine-use disorders, cannabis-use
disorders, cocaine-use disorders, hallucinogen-use disorders,
nicotine-use disorders, opioid-use disorders, schizophrenia,
schizoaffective Disorder, schizophreniform disorder, delusional
disorder, psychotic disorder, NOS, major depressive disorder,
depressive disorder, NOS, bipolar Disorders, panic disorder,
obsessive-compulsive disorder, PTSD, generalized anxiety
disorder, anxiety disorder, NOS, gender identity disorder, anorexia
nervosa, bulimia nervosa, binge eating disorder, eating disorder
NOS, primary sleep disorders, personality disorders, medicationinduced movement disorders, dementia, ADHD or confirmation of
suicide ideation or likely high risk of harm to the patient or others
reported by the patient, patient’s family or significant other reliable
persons.
 Order of a urine analysis, basic or comprehensive metabolic panel,
complete blood count, lipid panel, hemoglobin A1c, pregnancy test,
sexually transmitted infection screen (e.g.- RPR), thyroid function tests,
electrocardiogram (for medication tolerability evaluation).
 Standardized assessments related to psychiatric symptom evaluation or
medication tolerability and effectiveness, status/progress, including the
Abnormal Involuntary Movement Scale (AIMS), Barnes Akathisia Scale,
Simpson-Angus Scale (SAS), Patient Health Questionnaire (PHQ-9),
Mini-Mental State Exam (MMSE), Young Mania Rating Scale (YMRS),
Positive and Negative Syndrome Scale (PANSS), Global Assessment of
Functioning (GAF), the Sheehan Disability Rating Scale or the Pierce
Physician/Pharmacist Protocol – Psychiatric Medication Therapy Services (MTS)
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Suicide Intent Scale or the Beck’s Suicide Intent Scale and/or other
agreed-upon depression and suicide risk assessments. The clinical
pharmacist may, especially when the authorizing physician hereto is
unavailable or difficult to contact, take any legal action to prevent selfharm or harm to others by the patients under the care of this
protocol/Agreement.
The clinical pharmacist may NOT initiate or modify any controlled
substance treatments.
The clinical pharmacist agrees to complete and confirm the successful
completion and passing score on accompanying test(s) of at least 1 hour of
C.E. Credit (as approved by any national or state approved organization to
grant such credits to any health or mental health profession) annually.
Provide medication therapy services (MTS) which includes the initiation,
titration, taper, or discontinuation of the following psychiatric medications
(all dosing shall adhere to currently accepted FDA-labeling and
guidelines):
1. Antipsychotics: haloperidol (Haldol®), chlorpromazine
(Thorazine®), thioridazine (Mellaril®), loxapine (Loxitane®),
perphenazine (Trilafon®), trifluoperazine (Stelazine®), thiothixene
(Navane®), fluphenazine (Prolixin®), clozapine (Clozaril®),
risperidone (Risperdal®), olanzapine (Zyprexa®), quetiapine
(Seroquel®), ziprasidone (Geodon®), aripiprazole (Abilify®),
paliperidone (Invega®), asenapine (Saphris®), iloperidone
(Fanapt®), lurasidone (Latuda™)
2. Anticholinergic Agents: benztropine (Cogentin®),
trihexyphenidyl (Artane®), diphenhydramine (Benadryl®),
hydroxyzine (Vistaril®)
3. Mood Stabilizers: lamotrigine (Lamictal®), valproate
(Depakote®), oxcarbazepine (Trileptal®), carbamazepine
(Tegretol®), lithium (Lithobid®), topiramate (Topamax®)
4. Antidepressants: fluoxetine (Prozac®), sertraline (Zoloft®),
paroxetine (Paxil®), fluvoxamine (Luvox®), citalopram (Celexa®),
escitalopram (Lexapro®), bupropion (Wellbutrin®), trazodone
(Desyrel®), nefazodone (Serzone®), venlafaxine (Effexor®, Effexor
XR®), desvenlafaxine (Pristiq®), duloxetine (Cymbalta®),
mirtazapine (Remeron®), vilazodone (Viibryd™), Selegiline
(Emsam®), desipramine (Norpramin®), nortriptyline (Pamelor®),
protriptyline (Vivactyl®), amitriptyline (Elavil®), imipramine
(Tofranil®), clomipramine (Anafranil®), doxepin (Sinequan®),
atomoxetine (Strattera®)
5. Anxiolytic Agents: buspirone (Buspar®)
6. Antihypertensives (for psychiatric purposes): propranolol,
clonidine, prazosin
7. Nicotine Dependence Treatments: varenicline (Chantix®),
nicotine replacement therapy (patches, gum, lozenge, inhaler)
8. Glucometers, test strips, and lancets for diabetes management
Physician/Pharmacist Protocol – Psychiatric Medication Therapy Services (MTS)
9. Vitamins, Other O-T-C Products Such As: folic acid, thiamine,
multivitamin, cyanocobalamin (B12). L-tryptophan, Sam-e, St.
John’s Wort, 5-hydroxytryptophan (5-HT)
IV.
Quality Assurance: a sample of current (within the past 90 days) progress
notes will be discussed with the referring physician. The delegating physician
will provide in-depth written or recorded verbal review on 10% of progress
notes submitted by the clinical pharmacist monthly, including the names of
the patients reviewed, the physician’s name and the date of the review.
(Print)___________________________
MTS Pharmacist, R.Ph.
Psychiatric Clinical Pharmacist
(Print)__________________________
Physician’s Name, M.D. or D.O.
Authorizing Physician/Psychiatrist
______________________________
Signature
______________________________
Date
_________________________________
Signature
_________________________________
Date
Pharmacy or Practice Name/ Location
Street, City, Zip, Missouri
E-Mail Address__________________
Office or Practice Name
Street, City, Zip, Missouri
E-mail Address____________________
Office Phone: ____________________
Office Phone _____________________
Mobile Phn: _____________________
Mobile Phn: _____________________
Physician/Pharmacist Protocol – Psychiatric Medication Therapy Services (MTS)