BOP Program Statement 6360.03 § 3

Each institution will maintain a pharmacy directed by a professionally and legally qualified

pharmacist(s), pharmacy technician(s), medication technician(s), and support staff sufficient in

keeping with the size of the institution and the scope of medical services provided.

At a minimum, institutions utilizing Central Fill and Distribution (CFAD) must be staffed by

trained medication technician(s). Additional pharmacy staff, to include pharmacists, may also be

required dependent on institution volume, care level, and as determined by the Health Services

Division (HSD).

a. Hours of Operation.

 Non-MRCs will normally be day shift, Monday – Friday, excluding holidays.

 All institutions are not normally staffed on holidays, weekends, or beyond 6:00 PM on

weekdays without Central Office (CO) approval.

 Planned closures of pharmacy due to scheduled leave (e.g., annual training, scheduled

medical procedures, etc.) must have concurrence by the Regional Medical Director and

Regional Chief Pharmacist.

b. Options During the Absence of the Pharmacist. During periods when a pharmacist is not

able to perform their normal duties (e.g., annual training, continuing medical education, periods

of leave, vacancies, special projects, etc.) one of the following options will be used:

 TDY Within the Bureau. Arrange for TDY assistance from another Bureau pharmacist.

TDY assistance should not leave another institution without pharmacist coverage (e.g., TDY

from an institution with only one pharmacist).

 Contracting (Amend Existing Contract). Include a requirement for pharmacist

coverage in the comprehensive medical contract.

6360.03 5/7/2026 PROPERTY OF US GOVERNMENT 3

 Contracting (Establish Separate Contract). Contract with a firm that provides

temporary pharmacist services using open market procurement procedures or existing

Federal Supply Schedules (FSS).

 Obtain the Services of a Second Pharmacist. A second pharmacist provides the added

benefit of coverage of vacations, training, and sick leave, as well as increased clinical

services.

The use of physicians to cover for pharmacists is not an adequate solution as the roles of each are

distinct in healthcare. Physicians are responsible for diagnosing and treating inmates and may

only dispense medications in emergency situations. All the above options must be actively

pursued and exhausted prior to using a physician to provide pharmacist coverage. Institutions

without the services of a pharmacist for greater than one business day will require a waiver to

policy to utilize physician verification for the period covered by the physician.

Although dentists and licensed clinical social workers have “independent status,” they are not

allowed to dispense, as most medications fall outside their scope of practice. Health care

providers, such as APPs, EMTs, nurses, medication technicians, and pharmacy technicians do not

have independent status and may not be assigned pharmacist-specific dispensing duties.