Rx & The Law

"Pill Splitting" - Is It Legal?  Is It Covered By Malpractice Insurance?

By Kenneth R. Baker, B.S.Pharm., J.D.
Vice President, General Counsel
Pharmacists Mutual Insurance Company

Several pharmacists have called asking these questions regarding “pill splitting”.[1]  These pharmacists have indicated they are receiving requests from third party payers and from physicians, and occasionally from patients, to split some prescription medications prior to dispensing.  In most cases the questions involve unscored tablets and in most cases, the reason for the request is to save money for the patient or the third party payer. 

The real question for the pharmacist involves two considerations – the law and pharmacy judgement.  Whether the pharmacist can “split” unscored tablets is determined by both considerations.  In most states, at present, there are no laws or pharmacy regulations specifically forbidding “pill splitting”, although there are warnings in pharmacy literature discouraging it.  The pharmacist, asked to “split” tablets, needs to know if there is a legal restriction in the state in which he or she practices. 

As part of the legal consideration, the manner in which the prescription is written becomes important.  If the prescription indicates “DrugX, 50 mg”, it must be filled exactly as written.  In order to fill the prescription with a split DrugX, 100 mg tablet, the pharmacist must be able to split the tablet in a manner that assures each one-half contains exactly 50 mg of DrugX.  Therein lies the problem.  An unscored tablet cannot be divided exactly equally.  Without the prescriber’s specific orders to split the tablet, the prescription may not have been filled as ordered.  This may be a violation of the state pharmacy practice act. 

Even if the doctor does order or approve the split “into two parts of approximately the same strength”, the pharmacist’s act of splitting the tablets into strengths commercially available, may arguably amount to illegal compounding under Section 503A[2]  of the FDA Modernization Act of 1997.  It may be argued that the compounding definition is broad enough to include preparation of a dose by splitting the tablets.  If so, and if the resulting one-half dose is commercially available, the action could be interpreted as a violation of the federal statute which says:  “A drug product may be compounded . . . if the licensed pharmacist . . . (D) does not compound regularly or in inordinate amounts (as defined by the Secretary) any drugs products that are essentially copies of a commercially available drug product." [3] (emphasis added).

Even if the law allows it, the decision must be made by the pharmacist based upon professional judgement and patient best interest.  Generally speaking, pill splitting by the pharmacist is not a good idea and should be avoided, absent some overriding consideration for a particular patient.
If the pharmacist knows a patient is going to split unscored tablets, the law will have little to say about the patient’s actions, but the pharmacist should consider the application of pharmaceutical care to the situation.  The pharmacist should: warn the patient about the inexactness of the resulting half table dosage; warn the patient of the possible effects of an inexact dose – too high or too low; and tell the patient to let his prescriber know that he/she is splitting tablets.  The pharmacist should also consider what other advice he/she should give. The pharmacist should be certain the patient understands that while cost is a legitimate consideration, it should not be the primary consideration.

The second question -- “Is it covered?” – is a product of the first.  Most policies contain an exclusion similar to this:  “This policy does not apply to . . . damages caused by your willful violation of a regulation or statute pertain to the practice of pharmacy . . . committed by you or with your knowledge or consent.”   (emphasis added).  If the action of “pill splitting” is known by the pharmacist to be a violation of the law, the exclusion applies.  If however, the pharmacist does not willfully violate the law, even if it later becomes apparent it is a violation, the policy would cover, in spite of the exclusion, even if the action is unwise.  A board of pharmacy or a court, however, may not care if the pharmacist was ignorant of the law and will not excuse the pharmacist who pleads, “I did not know about that rule”.  

The ultimate bottom line for the professional pharmacist is – if it is not good pharmacy practice, don’t do it.

[1] See, www.health24news.com, Holton,N., Pill Cutting for Cost Cutting, (March 2000, Health24)
[2] 21 U.S.C. 353 § 503A
[3] 21 U.S.C. 353 § 503A (b) (1)(D).

This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with the policies and procedures of their employers and insurance companies, and act accordingly.