COVID-19: Hydroxychloroquine, Chloroquine, and Azithromycin

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The chart below includes NASPA’s compilation of state actions affecting Hydroxychloroquine, Chloroquine, and Azithromycin. This is a work in progress.

The following are other relevant links:

Return to COVID-19: Information from the States

State Date Guidance
Alabama 3/25/2020 Pharmacists should use their professional judgement when filling prescriptions for hydroxychloroquine and chloroquine.
Alaska 4/1/2020 Medicaid claims for hydroxychloroquine and chloroquine requre ICD-10 diagnosis code regardless of indication. These medications are not for use for COVID-19 prophylaxis, and the quantity limit is 28 dosage units per claim. COVID-19 cases must be confirmed before using medications as treatment.
Arizona 4/2/2020 The following is required when filling hydroxychloroquine and chloroquine: • The prescription must be presented with a diagnosis code for COVID-19 from the prescriber.
• For a phoned-in prescription, the pharmacist must document a diagnosis code for COVID-19.
• The prescription is limited to no more than a 14-day supply.
• No refills may be permitted unless a new prescription is furnished.
• Prophylactic prescriptions for the prevention of COVID-19 are strictly prohibited unless peer-reviewed evidence citing prophylactic effectiveness becomes available.
• This section does NOT apply to patients that are taking hydroxychloroquine and/or chloroquine for treatment other than COVID-19 (i.e. autoimmune disease) or to prescriptions written prior to April 2, 2020.
Arkansas 3/21/2020 Pharmacists should exercise caution, keeping in mind that there are no FDA approved treatments for COVID19 at this time; monitor supplies of hydroxychloroquine and chloroquine; and encourage prescribers to note indication (lupus, etc) on prescription when sending to pharmacy.
California 4/1/2020 The California Department of Consumer Affairs, the Medical Board of California, and the California State Board of Pharmacy remind health care professionals that inappropriately prescribing or dispensing medications constitutes unprofessional conduct in California. Prescribers and pharmacists are obligated to follow the law, standard of care, and professional codes of ethics in serving their patients and public health.
Colorado 3/26/2020 (From Colorado DORA) 1. Continue to fill prescriptions for existing patients who are being prescribed these medications for FDA-approved indications on chronic therapy.
2. For new prescriptions, prescribers should be cognizant that hydroxychloroquine use in COVID-19 patients is not the standard of care. Pharmacists should verify and document diagnosis with the prescriber or prescriber’s agent and limit to a 30-day supply of medication with the drug frequently on back order at this time for prescriptions with an FDA-approved indication.
3. Due to limited supply, reserve hydroxychloroquine for patients with known autoimmune disorders and those ill enough to be hospitalized for COVID-19.
Connecticut 4/6/2020 From CT Department of Public Health
Off Label Use of Hydroxychloroquine and Azithromycin: The FDA issued an EUA allowing hydroxychloroquine sulfate and chloroquine phosphate products donated to the Strategic National Stockpile to be distributed and prescribed by doctors to hospitalized teen and adult patients with COVID-19, as appropriate, when a clinical trial is not available or feasible.
CT DPH strongly advises against off-label use of hydroxychloroquine and azithromycin in the outpatient setting for COVID-19 prophylaxis or treatment due to lack or safety and efficacy data. Both these medications should be conserved for those who require them for indicated purposes.
Delaware 3/24/2020 The Division of Professional Regulation encourages prescribers, pharmacies, and pharmacists to adopt policies such as limiting quantity dispensed and restricting use to certain patient populations. DPR asks prescribers to refrain from prescribing these drugs prophylactically for COVID-19 exposure to ensure that patients with chronic disease can continue to manage their diseases and that the most critically ill get the medication they need.
Florida
Georgia
Hawaii
Idaho 3/26/2020 1. No prescription for chloroquine or hydroxychloroquine may be dispensed unless all of the following apply: a. The prescription bears a written diagnosis from the prescriber consistent with the evidence for its use; b. The prescription is limited to no more than a fourteen (14) day supply; and c. No refills may be permitted unless a new prescription is furnished. d. The provisions of subsections b and c do not apply if the patient was previously established on the medication prior to the effective date of this rule. 2. No prescription for oral azithromycin may be dispensed unless all of the following apply: a. The prescription bears a written diagnosis from the prescriber consistent with the evidence for its use; b. The prescription is limited to no more than a five (5) day supply; and c. No refills may be permitted d. The provisions of subsections b and c do not apply if the patient was previously established on the medication prior to the effective date of this rule.
Illinois
Indiana 4/1/2020 For Pharmacists:
• Pharmacists should use their professional judgment and take appropriate steps to verify that newly issued prescriptions for hydroxychloroquine, chloroquine and azithromycin are issued for a legitimate medical purpose. To prevent drug shortages, the Board recommends contacting prescribers to confirm the diagnosis for patients newly prescribed these medications during the Public Health Emergency.
• The Board recommends that licensees limit supplies of hydroxychloroquine, chloroquine and azithromycin prescribed for presumptive COVID-19 positive patients or prophylactic use. Multiple states have adopted a 14-day supply limit. While Indiana has not adopted a similar limit at this time, licensees should consider limited dispensing for patients newly prescribed hydroxychloroquine, chloroquine or azithromycin during the Public Health Emergency without a supporting medical diagnosis.
• The Board is not recommending that pharmacies refuse to fill, the Board is recommending that pharmacies use caution.
While both Boards are recommending caution, licensees should avoid interruptions in care for patients previously established on these medications with an appropriate medical diagnosis. The Boards recognize this may be a difficult balance, however, licensees should make a good faith effort to ensure appropriate prescribing, dispensing and patient care.
Iowa 3/23/2020 Pharmacies are strongly encouraged to assess their current and potential supply and implement policies that will ensure adequate supply for patients who were previously established on the drug.
Kansas 3/24/2020 The Board strongly encourages vigilance in processing new prescriptions for chloroquine and hydroxychloroquine and recommends reaching out to prescribers to verify diagnosis.
Kentucky 3/20/2020 The pharmacist must use professional judgement to determine if a valid patient-prescriber relationship exists and keep in mind if there is enough of the drug in stock to treat RA patients who receive it on a regular basis when deciding whether or not to dispense the prescription.
Louisiana 3/25/2020 With respect to the dispensing of chloroquine and hydroxychloroquine for the COVID-19 outbreak, the Board strongly encourages dispensing pharmacists in community pharmacies to ensure the prescription bears a COVID-19 diagnosis, and to dispense a maximum of a 14-day supply, with no refills unless a new prescription is presented.
With respect to the dispensing of chloroquine and hydroxychloroquine for all other diagnoses, the Board strongly encourages dispensing pharmacists in community pharmacies to dispense a maximum of a 30-day supply per dispensing.
The Board specifically encourages pharmacists to exercise their professional discretion when presented prescriptions written for large quantities, or for what appears to be outside the context of a legitimate physician-patient relationship, or for what may not be a legitimate medical purpose.
Maine 4/11/2020 Pharmacists should use their professional judgment and take appropriate steps to verify that newly issued prescriptions for chloroquine, hydroxychloroquine, and azithromycin are issued for legitimate medical purposes and not for prophylactic treatment unless consistent with prescribing guidelines of the Food and Drug Administration and the Centers for Disease Control and Prevention. To prevent drug shortages, pharmacists should contact prescribers to confirm the diagnoses of patients newly prescribed these medications, and pharmacies should refrain from inappropriately stockpiling these medications. A pharmacist should expect that a prescription for these medications for purposes of treating COVID-19 contain a diagnosis code of an active or presumed case of COVID-19 and be limited to a 14-day supply. Pharmacists should continue to fill prescriptions for up to 90-day supplies for patients who have existing prescriptions for any of these medications for treatment of conditions other than COVID-19.
Maryland
Massachusetts
Michigan
Minnesota 3/23/2020 The Board will support pharmacists who, in good faith and based on their clinical assessment of the situation, refuse to dispense prescriptions for such drugs (chloroquine, hydroxychloroquine, and azithromycin) that prescribers issue for themselves, their family members, or their friends. Pharmacies are always prohibited from ordering any drugs from manufacturers and wholesalers and then selling them in more than minimal quantities to practitioners. In the case of drugs used to prevent or treat COVID-19, it would be appropriate for pharmacists to inquire about the need and intended use of the drugs before selling even minimal quantities for office use. In addition, while pharmacists are required to fill prescriptions that pharmacists are reasonably expected to fill, pharmacies and pharmacists are not required to sell any medication to practitioners for office use.
Mississippi 3/24/2020 Pharmacists should exercise caution dispensing hydroxychloroquine and chloroquine in a community setting. Pharmacists should use their professional judgment when dispensing these medications for non-FDA approved indications and are allowed to deny prescriptions if neccessary.
Missouri Pharmacists should use their professional judgment and take appropriate steps to verify that newly issued prescriptions for hydroxychloroquine, chloroquine and azithromycin are issued for a legitimate medical purpose. To prevent drug shortages, the Board recommends contacting prescribers to confirm the diagnosis for patients newly prescribed these medications during the State of Emergency. The Board recommends that licensees limit supplies of hydroxychloroquine, chloroquine and azithromycin prescribed for presumptive COVID-19 positive patients or prophylactic use. Licensees should consider limiting dispensing for patients newly prescribed hydroxychloroquine, chloroquine or azithromycin during the State of Emergency without a supporting medical diagnosis. The Board is not recommending that pharmacies refuse to fill, the Board is recommending that pharmacies use caution.
Montana
Nebraska
Nevada 3/24/2020 Restrictions prohibit the prescribing and dispensing of chloroquine and hydroxychloroquine for a COVID-19 diagnosis or any new diagnosis made after the effective date of the regulation, and require an ICD-10 code and a limit to a 30 day for any new prescription for these drugs. The provisions of this emergency regulation do not apply to a chart order for an inpatient in an institutional setting or to an existing course of treatment for a diagnosis made before the effect date of the regulation.
New Hampshire 4/3/2020 Executive Order:
Chloroquine, hydroxychloroquine, and albuterol inhalers shall be subject to the following controls, restrictions, and rationing:
a) Outpatient prescriptions for patients not already established on chloroquine and hydroxychloroquine shall be limited to a 30-day supply.
b) No prescriptions of chloroquine or hydroxychloroquine shall be issued or dispensed as prophylaxis treatment for COVID-19.
c) Prescribing providers, when issuing a prescription in any form for chloroquine or hydroxychloroquine, must document an indication for all patients, including patients already established on these medications.
d) For albuterol inhalers, prescribing providers shall limit prescriptions to one inhaler with up to three refills for all new prescriptions to treat respiratory symptoms of COVID-19.
e) For all prescriptions of albuterol inhalers, pharmacists shall conduct a prospective drug utilization review to ensure adherence to asthma controller or maintenance medications, and counsel patients that are non-compliant and over-utilizing rescue inhalers.
New Jersey 3/29/2020 DCA Administrative Order:
1. Pharmacists shall refuse to fill prescriptions for any medication that may be in short supply due to their use in possible treatment of COVID-19 unless they contain a diagnosis or diagnostic code.
2. All dispensing of hydroxychloroquine or chloroquine for treatment of COVID-19 shall be limited to prescriptions supported by a positive test result, which must be documented on the prescription. Dispensing is limited to a 14-day supply, with no refills permitted.
3. Patients who present maintenance prescriptions for certain pre-existing conditions, such as lupus or other autoimmune disease, may continue to obtain refills of hydroxychloroquine and chloroquine, and shall not be subject to the 14-day limitation. If presented with a new prescription for hydroxychloroquine and chloroquine for a pre-existing condition, the prescription shall contain a diagnosis or diagnostic code which supports continue dispensing with refills.
4. Pharmacists shall not fill prescriptions for drugs for treatment of COVID-19 where the pharmacist believes the prescriber is acting outside of the scope of his or her practice.
5. Pharmacists may exercise judgment when filling or refilling prescriptions for medications that may soon be in short supply due to increased demand of certain drugs or drug delivery systems due to the COVID-19 pandemic. For example, the demand for metered dose inhalers (MDI) has increased. In there situations, dispensing one MDI, when a prescription was written for three, may be a prudent decision.
6. These restrictions and limitations do not apply to dispensing pursuant to medication orders for inpatient hospital use OR state or federal clinical trials.
New Mexico 3/21/2020 The Board does not intend to take action against a pharmacist or pharmacy that declines to fill a questionable prescription for such medications (chloroquine, hydroxychloroquine, mefloquine, Kaletra, azithromycin, etc.), or limits the day supply dispensed for an acute condition to the recognized duration of treatment for the same based on the drug. Pharmacists are expected to exercise due diligence and professional judgment in such determinations, including communicating with the practitioner and patient as practicable. Pharmacists are to be aware of current recommendations and indications for the prescribed drug as part of the determination whether to fill a such a prescription.
New York 3/23/2020 No pharmacist shall dispense hydroxychloroquine or chloroquine except when written as prescribed for an FDA-approved indication; or as part of a state approved clinical trial related to COVID-19 for a patient who has tested positive for COVID-19, with such test result documented as part of the prescription. No other experimental or prophylactic use shall be permitted, and any permitted prescription is limited to one 14-day prescription with no refills.
North Carolina 3/22/2020 Pharmacists are reminded of their ability to refuse to fill prescriptions that, in the pharmacist’s professional judgment, are not clinically appropriate. Exercising that professional judgment may include setting reasonable policies designed to ensure that prescription drugs are available for all patients, including use of partial fills for limited days’ supply and otherwise ensuring that patients taking these medications for established, and approved, indications do not have their drug therapy interrupted.
North Dakota
Ohio 3/22/2020 Unless otherwise approved by the board’s executive director, no prescription for chloroquine or hydroxychloroquine may be dispensed by a pharmacist or sold at retail by a licensed terminal distributor of dangerous drugs unless all the following apply:
(1) The prescription bears a written diagnosis code from the prescriber; and
(2) If written for a COVID-19 diagnosis, the diagnosis has been confirmed by a positive test result, which is documented on the prescription and both of the following apply:
(a) The prescription is limited to no more than a fourteen-day supply; and
(b) No refills may be permitted unless a new prescription is furnished.
Prescriptions for either presumptive positive patients or prophylactic use of chloroquine or hydroxychloroquine related to COVID-19 is strictly prohibited unless otherwise approved by the board’s executive director in consultation with the board president, at which time a resolution shall be issued.
Oklahoma 5/12/2020 On May 12, Governor Kevin Stitt enacted an Executive Order that removed all restrictions regarding prescriptions for Hydroxychloroquine and Chloroquine. An OSBP COVID-19 waiver is no longer necessary for Hydroxychloroquine/Chloroquine prescriptions. The COVID-19 waiver request form is still available for a request for consideration to waive Oklahoma Pharmacy Rules during the COVID-19 pandemic.
Oregon 3/25/2020 Oregon Board of Pharmacy adopts temporary emergency rule (OAR 855-007-0085) prohibiting the dispensing of chloroquine and hydroxychloroquine for presumptive treatment or prevention of COVID-19 infection to preserve supplies for treatment of malaria, inflammatory conditions, and documented COVID-19 infection in hospitalized or residential patients.
Pennsylvania 3/26/2020 In response to COVID-19 and potential shortages of medications that may be effective against the virus such as hydroxychloroquine, pharmacists should verify the patient is confirmed COVID-19 positive before dispensing. Patients established on therapy or utilizing the medication for other diagnoses (e.g. Lupus or Rheumatoid Arthritis) should be able to continue to access without diagnosis verification. Smaller quantities of hydroxychloroquine should be dispensed to COVID-19 patients when appropriate to prevent potential shortages.
Rhode Island 3/22/2020 No practitioner shall prescribe any medication for COVID-19, either for treatment or prevention, unless treatment or prevention of COVID-19, or similar infectious disease, is within such practitioner’s usual and customary scope of practice.
Any practitioner who chooses to prescribe an FDA-approved medication for the off-label purpose of treating COVID-19 shall:
(1) Indicate on the prescription the applicable ICD-10 diagnosis code.
(2) Indicate on the prescription a telephone number at which the dispensing authority (e.g., pharmacist) may reach the health care provider to address questions relative to dose and treatment.
(3) Document in the associated patient’s medical record that the specific risks and benefits of the off-label treatment were discussed with the patient.
(4) Document in the associated patient’s medical record the clinical rationale for the off-label prescribing, citing:
(a) At least one peer-reviewed article that justifies the clinical decision for the off-label prescribing, in the event that the FDA publishes such guidance.
(b)Applicable FDA guidance justifying the clinical decision for the off- label prescribing, in the even that the FDA publishes such guidance.
South Carolina 3/25/2020 1. Physicians should not prescribe Hydroxychloroquine, Chloroquine, and Azithromycin to themselves or family members unless faced with a bona fide emergency involving an actual diagnosis of a COVID-19 infection; 2. Physicians should consider the tremendous stress placed upon the supply chain by prescribing Hydroxychloroquine, Chloroquine, and Azithromycin prophylactically and/or simply for the patient to have available in the event the patient develops a COVID-19 infection. Physicians should also consider that irresponsible prescribing can prevent patients with a diagnosed COVID-19 infection from receiving these 3 drugs, even in an hospital setting, should they be determined to be effective in treating the condition. 3. Physicians should include a bona fide diagnosis on any prescription issued for Hydroxychloroquine, Chloroquine, and Azithromycin and could be subject to discipline for including an inaccurate diagnosis. 4. Pharmacists should use their professional judgment in determining whether to fill prescriptions for Hydroxychloroquine, Chloroquine, and/or Azithromycin and should consider the needs of patients previously prescribed these medications for conditions for which the medications have been approved by the FDA or for which have been historically used off-label to treat certain conditions. Pharmacists should also consider the effect on the supply of Hydroxychloroquine, Chloroquine, and/or Azithromycin prior to filling prescriptions for these drugs. 5. As this is a fluid situation, the Boards will continue to monitor the supply of the medications, as well as additional data regarding their effectiveness in the treatment of COVID-19 as it comes available. Should the circumstances so dictate, the Board will issue additional guidance.
South Dakota 3/25/2020 From the Joint Statement of the American Medical Association, American Pharmacists Association, and American Society of Health-System Pharmacists on Inappropriate Ordering, Prescribing or Dispensing of Medications to Treat COVID-19 (referenced on the South Dakota BOP website): “We collectively support state and federal requirements that direct a prescription must be written only for a legitimate medical purpose. We also strongly support a pharmacist’s professional responsibility to make reasonable inquiries to a prescriber to resolve any questions about a prescription. If a prescription is not for a legitimate medical purpose, it should not be written, and it should not be dispensed. That determination can and should be made on a case-by-case basis, and physicians, pharmacists and other members of the healthcare team are more than capable of working together and resolving questions.”
Tennessee 3/26/2020 “We want providers and pharmacists to act with their best discretion to ensure patients continue to receive appropriate treatment in times of shortages. We discourage inappropriate prescribing or hoarding of this medication for prophylaxis or treatment of COVID-19, which may limit access for patients that require these medications for therapy for approved indications.”
South Carolina Pharmacists should use their professional judgment in determining whether to fill prescriptions for Hydroxychloroquine, Chloroquine, and/or Azithromycin and should consider the needs of patients previously prescribed these medications for conditions for which the medications have been approved by the FDA or for which have been historically used off-label to treat certain conditions. Pharmacists should also consider the effect on the supply of Hydroxychloroquine, Chloroquine, and/or Azithromycin prior to filling prescriptions for these drugs.
Texas 3/20/2020 No prescription or medication order for chloroquine, hydroxychloroquine, mefloquine, or azithromycin may be dispensed or distributed unless all the following apply:
(1) the prescription or medication order bears a written diagnosis from the prescriber consistent 9 with the evidence for its use;
(2) the prescription or medication order is limited to no more than a fourteen (14) day supply, unless the patient was previously established on the medication prior to the effective date of this rule; and
(3) no refills may be permitted unless a new prescription or medication order is furnished.
Utah
Vermont 3/20/2020 For the foregoing reasons, and on the basis of the foregoing authority and findings: Vermont retail pharmacists and pharmacies shall, for any newly established outpatient prescription drug order for a drug known or popularly believed to be under investigation for COVID-19 indications, and specifically for
• azithromycin,
• baloxavir,
• chloroquine,
• hydroxychloroquine,
• lopinavir,
• oseltamivir,
• remdesivir,
• ritonavir,
• sarilumab,
• sirolimus, and
• tocilizumab:
1. Apply enhanced drug utilization review, by requiring that: a. the prescription order includes a documented diagnosis from the prescriber; b. the diagnosis and drug are plausibly within the scope of the prescriber’s practice, if known; c. the drug is reasonably indicated for the diagnosis, as indicated by FDA approval or support by credible literature, meaning literature upon which a reasonable professional competent in clinical pharmacology would rely; and d. the drug is not prescribed in a quantity manifestly in excess of the patient’s anticipated need.
2. Regard as illegitimate and refuse any newly established outpatient prescription drug order that does not satisfy the required elements of enhanced drug utilization review.
3. Take reasonable steps to protect access for patients already prescribed these medications for established maintenance needs, or who may be newly and legitimately diagnosed with conditions for which these drugs are indicated.
4. Report any clearly inappropriate prescribing activity to the Executive Officer for the Board of Pharmacy, at: carrie.phillips@vermont.gov.
Virginia 3/25/2020 Prescriptions for chloroquine, hydroxychloroquine, mefloquine and azithromycin should be restricted in the outpatient setting and should require a diagnosis “consistent with the evidence for its use.”
Community pharmacists should use professional judgement to determine whether a prescription is valid and that there is a bona fide practitioner-patient relationship prior to dispensing.
Prioritize treatment for continuation of existing medication therapy, inpatient settings, and other indications where there is not an alternative therapy.
Advise against hoarding these medications or stockpiling.
Washington 3/24/2020 Providers and pharmacists should act with their best discretion to ensure patients continue to receive appropriate treatment in times of shortages.
PQAC discourages inappropriate prescribing of chloroquine and hydroxychloroquine for prophylaxis, which may restrict access for patients that really need appropriate therapy such as those patients in our state with lupus, rheumatoid arthritis, and malaria diagnoses.
West Virginia 3/21/2020 No prescription for chloroquine or hydroxychloroquine may be dispensed except if all the following apply:
(a) The prescription bears a written diagnosis from the prescriber consistent with the evidence for its use;
(b) The prescription is limited to no more than thirty (30) tablets, unless the patient was previously established on the medication prior to the effective date of this rule; and
(c) No refills may be permitted unless a new prescription is furnished.
This requirement does not apply to the patient previously established on the medication prior to the effective date of this rule.
Wisconsin
Wyoming 3/23/2020 For Azithromycin, Chloroquine and Plaquenil (Hydroxychloroquine: Pharmacists should use their professional judgment when they evaluate therapeutic appropriateness when determining whether or not they should dispense what was prescribed. Pharmacists may want to carefully evaluate prescriptions for these medications to help prevent shortages that can be caused by excessive prescribing. Some things pharmacists may want to consider could include:
Is there a diagnosis that is consistent with the evidence for its use from the prescriber?
Is this a routine medication for this patient?
Limiting what is dispensed to no more than a 14-day supply for prescriptions that do not have a diagnosis consistent with evidence for patients that have never received that medication before.

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