Independent pharmacies play a vital role in serving local communities, particularly when it comes to ensuring timely access to critical medications. However, many pharmacists face roadblocks when filling prescriptions for controlled substances—often due to wholesaler-imposed thresholds that are not well understood.

At RxPost, we are committed to helping independent pharmacies navigate these complexities so they can better serve their patients. Here’s what you need to know.

Why Are Patients Experiencing Delays?

The California State Board of Pharmacy has received increasing public concern from patients and advocates about the difficulty of filling prescriptions for controlled substances like opioids, ADHD medications, and anti-anxiety drugs. To understand these concerns, the Board has reviewed presentations from several stakeholders, including distributors like Cardinal Health and trade groups like the Healthcare Distribution Alliance (HDA).

One key factor? Threshold limits.

What Is a Threshold?

A threshold is the maximum amount of a specific drug family a pharmacy is allowed to order from a distributor within a certain period. These thresholds are:

• Set per drug family, based on historical purchase data and risk models.

• Not mandated by the DEA but are part of legal settlements requiring monitoring systems for suspicious orders.

• Enforced by wholesalers like Cardinal Health using predictive models that flag "unusual size, frequency, or pattern" in orders.

When a pharmacy exceeds its threshold, the order is flagged as a Suspicious Order Report System (SORS) event, and the distributor is required to report it to the state board. The order is then automatically held and canceled.

It’s important to note: A suspicious order is not an accusation of illegal activity. It simply triggers regulatory protocols.

The Real-World Impact on Pharmacies

Imagine a nearby pharmacy shuts down, and your store sees a sudden increase in patients and prescription volume. Even though your intentions are valid and demand is genuine, your wholesaler’s algorithm may still flag this surge in activity as suspicious—resulting in delayed shipments or canceled orders.

This is why understanding and managing your threshold is critical.

How to Increase Your Threshold: A Step-by-Step Guide

If you anticipate increased patient volume, follow these steps:

1. Proactively communicate with your wholesaler.

   • Reach out before a volume spike occurs—don't wait until you've been flagged.

2. Submit a formal threshold increase request.

   • For Cardinal Health, you can access their request form through their online portal. Here is Cardinal’s user guide

3. Explain the change in patient demand.

   • Give context: a nearby pharmacy closure, flu season uptick, or new practitioners sending patients your way.

4. Be patient but persistent.

   • Processing times vary—some requests may take a week or more. Follow up regularly if needed.

Important: Your distributor cannot share your current threshold level due to legal restrictions, but you can still request adjustments based on reasonable expectations.

Empowering Pharmacy Owners: What You Can Do Today

• Educate your staff about the significance of thresholds and how to recognize potential threshold events.

• Document patient volume changes that may justify threshold adjustments.

• Stay engaged with your wholesaler to maintain open lines of communication.

• Watch and learn: You can view the California Board of Pharmacy’s livestream presentation on this topic here.