Can Nurse Practitioners Prescribe Out-of-State?

As a nurse practitioner, I’ve called in a prescription for a patient out of state a time or two. Patients traveling who neglected to pack necessary medications call the office requesting a refill locally. Practicing within an hour of a state border, a handful of my even patients reside across state lines. Scope of practice regulations vary from state to state making it difficult for nurse practitioners to know where they stand when it comes to practicing and prescribing in different locations. Is it allowable for NPs to prescribe out of state?

Legal Players

Prescribing across state lines involves three key types of law – state law, federal law, and scope of practice law. At the federal level, authority to prescribe controlled substances is awarded by the DEA, a federal agency. The granting of licensure allowing nurse practitioners to practice, however, occurs at the state level. Additionally, states laws themselves detail nurse practitioner’s scope of practice when it comes to prescribing.

With multiple governing bodies involved in prescribing law, tensions naturally arise in determining just how medical providers may prescribe medications. Disconnect between state law and federal law, for example, arises related to out of state prescribing as it concerns interstate commerce. While states control the practice of medicine and nursing within their own borders, federal law mandates that states not impede ‘interstate commerce’. Some have argued that prohibiting prescriptions to be filled across state lines interferes with interstate commerce. In Iowa, for example, the Iowa Supreme Court ruled that the state could not limit pharmacies from filling prescriptions written by out of state providers based on these grounds (State v. Rasmussen).

Scope of Practice Considerations

Guidelines for prescribing out of state may be different for physicians, physician assistants, and nurse practitioners. Scope of practice regulations governing each profession place unique restrictions on prescribing. For nurse practitioners, state scope of practice law takes one of three approaches to handling prescriptions written by NPs licensed in another state:

1. Prescriptions written by out of state NPs are subject to the same rules as those written by NPs licensed in the state
2. Prescriptions written by out of state NPs are subject to the rules within the state which the NP is licensed
3. The filling of prescriptions written by nurse practitioners licensed out of state is prohibited

​Kentucky, for example, takes the first approach. Prescriptions for controlled substances written by out of state advanced practice nurses may only be dispensed up to the authority the NP would have if licensed in Kentucky. In contrast, Washington State takes the final approach. Pharmacists in Washington State are prohibited from filling prescriptions written by out of state nurse practitioners. 

State Specific Considerations

In addition to scope of practice laws specific to nurse practitioners, state laws applicable to all prescribing providers may affect the NP’s ability to prescribe across state lines. This is particularly true where it concerns controlled substances. Massachusetts, for example, only honors prescriptions for Schedule II controlled substances written by providers licensed in six other states. In contrast, Florida does not subject prescriptions written for controlled substances by out of state providers to Florida law. 

Pharmacy Perspective

State and federal laws also govern the filling of prescriptions by pharmacies which affect the nurse practitioner’s ability to prescribe. These laws specify when and how prescribing across state lines can occur. For example, prescribing controlled substances must occur in a bona fide patient-provider relationship. The same holds true when it comes to prescribing across state lines. To fill a prescription written by a provider in another state, in states where it is allowable, the pharmacist may only do so ‘in good faith’ that a provider-patient relationship exists.

State law may also place additional stipulations on filling prescriptions written by providers licensed out of state. Such requirements can include specifications as to the method by which the medication is prescribed. In Texas, for example, prescriptions for non-controlled drugs and Schedule III, IV, or V drugs may be issued by a provider in another state. Prescriptions for Schedule II medications, however, may only be filled if the prescription is issued on an official Texas prescription form, or if the pharmacy has an official plan, approved by the Texas Department of Public Safety, for filling out of state Schedule II prescriptions.

In Summary

Overall, for nurse practitioners in most states, prescribing across state lines is allowable. The prescribing of controlled substances, particularly Schedule II controlled substances, may be an exception to this generalization. Prescribing must always occur within the scope of practice for the state within which the NP is licensed, and often within the scope of practice in the state where the prescription is filled. Before prescribing out of state, nurse practitioners must familiarize themselves with prescribing law in the state where they practice, and the state(s) where they plan to prescribe.

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