11.1 Counseling and Offer to Counsel

Why the offer to counsel is its own Competency 2.3 leaf

Quick Answer: OBRA ’90 is a Medicaid floor: prospective DUR plus an offer to counsel. CGS § 20-620 is Connecticut’s Medicaid statute (patient record, 180-day review, eight-item counseling content). CGS § 20-614(d) — added by P.A. 19-191 — is the broader offer: before or simultaneous with dispensing from a Chapter 400j pharmacy, a pharmacist or other employee shall, whenever practicable, offer for the pharmacist to discuss the drug and counsel the patient. RCSA § 20-576-39 forbids a technician from doing that consult. A registered intern under RCSA § 20-576-9 may, because contemporary pharmacy services include counseling, but only with a pharmacist physically present and personally supervising. Document counseling, refusal, or inability for at least three years (§ 20-614(e) + § 20-615).

NABP Area 2.3 is not “be nice at the window.” It is who must offer, who may speak, what the talk must cover, how a refusal is recorded, and how a mail-order pharmacy satisfies the same duty without a counter. Chapter 6.3 kept the federal OBRA floor straight. This section opens the current Connecticut offer-to-consult language and the personnel split the exam actually grades.

Two Connecticut counseling statutes — do not collapse them

Section 4401 of OBRA ’90 (42 U.S.C. § 1396r-8(g); 42 CFR 456.705) required states, as a condition of Medicaid funding, to put a drug-use review program in place. The pharmacist-facing pieces are a patient profile, prospective DUR before each fill, and an offer to counsel the Medicaid patient or caregiver. That is a Medicaid floor, not a statement that cash-pay patients may be skipped. Connecticut answered twice.

CGS § 20-620 (transferred from former § 20-185g; the 1992 Medicaid implementation) still applies when the fill is for a Medicaid-eligible individual. Before or simultaneously with dispensing, the pharmacist or designee must make a reasonable effort to obtain and maintain name, address, telephone, date of birth or age, gender, significant history (disease states, allergies, reactions), a comprehensive list of drugs and relevant devices the pharmacy dispensed in the last 180 days, and pharmacist comments. The pharmacist must review drugs dispensed by that pharmacy during those 180 days for duplication, drug-disease and drug-drug problems, dose and duration, allergy, and clinical abuse or misuse. Subsection (c) then requires an in-person offer, whenever practicable, to discuss the drugs and counsel the client — with the same written-offer escape hatch later copied into § 20-614. Subsection (f) carves nursing-home patients when the facility complies with 42 CFR 483.60 (federal long-term-care pharmacy services). That carve-out is a Medicaid/OBRA sentence; do not import it as a blanket community exemption.

CGS § 20-614(d)–(e) is the 2019 overlay. P.A. 19-191 added the offer and the recordkeeping subsections to the same statute that already governed prescription form. P.A. 21-37 then tied subsection (d) to a pharmacy licensed pursuant to this chapter, so the offer is not limited to the Medicaid claim on the screen. Read § 20-614 as the general Connecticut offer-to-consult rule, and § 20-620 as the Medicaid content-and-profile rule that still supplies the eight-item counseling checklist.

The current offer-to-consult language — CGS § 20-614(d)

Prior to or simultaneous with the dispensing of a drug, from a pharmacy licensed pursuant to Chapter 400j, a pharmacist or other employee of the pharmacy shall, whenever practicable, offer for the pharmacist to discuss the drug to be dispensed and to counsel the patient on the usage of the drug, except when:

1. The person obtaining the prescription is other than the person named on the prescription form or electronic record; or
2. The pharmacist determines it is appropriate to make such offer in writing.

Any written offer shall include an offer to communicate with the patient either in person at the pharmacy or by telephone.

Three exam consequences sit in that paragraph:

• The offer may come from a technician, clerk, intern, or cashier. The discussion is “for the pharmacist.” Handing a bag and saying “any questions for the pharmacist?” can satisfy the offer. Explaining the new warfarin SIG is not a technician task.
• The statute does not limit the offer to new prescriptions. It fires on dispensing. A chronic refill still gets an offer. How deep the counseling goes on a fifth refill of the same atorvastatin is professional judgment; skipping the offer because “it’s a refill” is not.
• Whenever practicable is not a license to skip every Saturday rush. It is the same phrase § 20-620 uses. If the patient is at the window, an in-person offer is practicable. If a caregiver is picking up, the statute itself points you to a written offer that still includes telephone access.

CGS § 20-614(e) then closes the loop: nothing requires a pharmacist to counsel a patient who refuses. The pharmacist shall keep a record of the counseling, of any refusal by or inability of the patient to accept counseling, or of a refusal to provide information regarding counseling. Those records are kept for the same length of time as prescription records under CGS § 20-615 — not less than three years. An undocumented “they said no” is a missing record, not a completed offer.

Who may actually counsel

Do not invent a statutory intern counseling ban. Chapter 4 already warns that § 20-576-39 is written for technicians, not copied into § 20-576-9. Do not let that intern replace the pharmacist on final verification either. The MPJE stem that puts a technician “just explaining the directions” while the pharmacist is in the parking lot is a § 20-576-39 miss, and RCSA § 20-576-38 still aims discipline at the supervising pharmacist’s license.

What the counseling must cover

Section 20-614 says “discuss the drug” and “counsel … on the usage.” It does not reprint a numbered list. CGS § 20-620(d) does, and it matches the federal OBRA counseling elements in 42 CFR 456.705. Treat that eight-item list as the content standard the exam expects, for Medicaid and as the professional checklist on any fill where counseling is accepted:

1. Name and description of the drug
2. Dosage form, dosage, route of administration, and duration of therapy
3. Special directions and precautions for preparation, administration, and use
4. Common severe side or adverse effects or interactions and therapeutic contraindications the pharmacist deems relevant
5. Techniques for self-monitoring
6. Proper storage
7. Prescription refill information
8. Action if a dose is missed or an adverse reaction occurs

A New Haven pharmacist who only reads the SIG out loud has not covered storage, interactions, or missed-dose action. A Waterbury pharmacist who dumps all eight items onto a patient who already declined has ignored § 20-614(e) — refusal ends the duty to counsel, not the duty to record the refusal.

Mail-order, delivery, and nonresident pharmacies

Connecticut does not pretend every fill happens at a Stamford window.

• When the person obtaining the prescription is not the patient, § 20-614(d) itself substitutes a written offer that still includes in-person or telephone communication.
• When the pharmacist determines a written offer is appropriate — a classic mail-order or delivery fact pattern — the same written offer applies. A printed counseling leaflet with a callback number is the method; an unsigned bag stuffed in a mailbox with no offer is not.
• CGS § 20-627 defines a nonresident pharmacy as a pharmacy located outside Connecticut that ships, mails, or delivers legend drugs or devices into this state pursuant to a prescription. § 20-627(b)(7) requires a toll-free telephone number to facilitate communication between Connecticut patients and a pharmacist at that pharmacy who has access to the patient’s records at all times. That number shall be disclosed on a label affixed to each container dispensed to a Connecticut patient. § 20-628 forbids the shipping business without a Commission certificate of registration.

A Florida mail-order pharmacy filling a Hartford patient’s maintenance medications is not excused from counseling because “we don’t have a counter in Connecticut.” The method is telephone access to a pharmacist who can see the profile, advertised on the label, plus whatever written offer the home-state and Connecticut rules require. Prospective DUR (Chapter 12) still runs; the counseling method is what this leaf tests.

Realistic Connecticut scenario

A technician in a West Hartford community pharmacy bags a new levofloxacin and a refill of metformin. She tells both patients, “The pharmacist is available if you have questions,” and notes the offers. That is a lawful § 20-614(d) offer by “other employee.” If the levofloxacin patient says yes, the technician does not explain tendon-rupture risk — she pages the pharmacist (or a personally supervised intern). If the metformin patient says no, the pharmacist still records the refusal and keeps it with the prescription file for at least three years. The next patient is a son picking up his mother’s new warfarin; the person at the counter is not the patient, so the pharmacy issues a written offer that includes a telephone consult, not a hallway lecture to the son about INR targets in front of the waiting line. A nonresident mail-order fill of the same warfarin must show the toll-free pharmacist line on the label.

Official anchors

• CGS § 20-614 — offer to consult, written-offer substitute, counseling records.
• CGS § 20-620 — Medicaid profile, 180-day review, eight-item counseling content, nursing-home exception.
• CGS § 20-615 — prescription records not less than three years.
• CGS § 20-627 — nonresident toll-free pharmacist access on the label.
• RCSA § 20-576-39 — technician counseling prohibition.