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Medication Donation Form

Thank you for donating meds with RemediChain!

Submission of this form meets the requirements of the Prescription Donation Repository Program established by the Kevin Clauson Drug Donation Act, Tennessee Code Annotated, Title 63, Chapter 10. All participants in the program must act in good faith and agree to make donations in accordance with the Act. RemediChain accepts medication that is unopened, unexpired, and in its original packaging. This may include blister packs, as long as unused doses remain sealed. It does not include loose pills, even those in pharmacy-issued brown bottles. We cannot accept controlled substances or refrigerated medications.

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

First Name*

Last Name*

Phone Number*

Email Address*

Shipping Address*

RemediChain can legally accept donations of unused medications from anywhere in the United States of America. Including your shipping address on this form ensures our compliance and, ultimately, the safety of the donated medications being shared with other patients. We'll never share or sell your personal contact information.

Street Address City State ZIP Code

What is the dosage form of the medication you'd like to donate?*

Medication Name*

Brand names are acceptable. If you have a generic, you can put the specific medication name as written on the prescription label. If it says "generic for" with a brand name, you can write that too.

Dose/Strength*

This information is usually available on the prescription label. For example, a single pill may be 4mg. If you're not sure, just write "unsure."

How much do you have?*

Here, we're looking for the number of pills/units.

Is this medication a controlled substance?*

Yes

No

Does this medication require any special handling (for example, refrigeration)?*

Yes

No

Is the medication unexpired, with at least six months until its expiration date?*

Yes

No

Is the medication in its original manufacturer's packaging (no brown pharmacy bottles or other alternate containers)?*

Yes

No

Is the medication in a SEALED package (foil-sealed, blister packs, etc.)?*

Yes

No

How did you hear about RemediChain?

Check all that apply.

Social Media (Facebook, YouTube, LinkedIn, etc.)

Health Care Provider or Social Worker

Friend/Family Member

News Story

Search Engine (Google, etc.)

Message Board (Reddit, etc.)

Advertisement

Unsure

Will you help us understand why this medication is unused and available for donation?

Check all that apply. This question is for research purposes only and will not be shared. Your answer will not be connected to your name or other identifiable information.

The patient had negative side effects with this medication.

The patient passed away before using the medication.

The patient's health issues have resolved and the medication is no longer necessary.

The patient's health condition changed, requiring a different medication or dosage.

The pharmacy filled the prescription with a multi-month supply, and the patient did not need all of it.

The patient did not take the medication as often as prescribed and wound up with more than necessary.

Other

Please explain your selection of "other" in the previous question.

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Alabama

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Patient; Patient Relative (adult child, spouse, sibling, parent, legal guardian, administrator of patient estate)

Repositories: Charitable Clinic; Community Health Center

Patients: Charitable Patients
* Does not include patients who are eligible for Alabama Medicaid Program or other patients covered by the State of Alabama

Notes: Must be unit dosed and individually sealed dosed containers. No medicaid/controlled substance restrictions. Can accept medications in bulk containers from hospice programs only.

Nevada

Donation & Reuse Laws: No

Operational Program: No

Tennessee

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Person; Pharmacy; Medical facility; Drug manufacturer or wholesaler licensed by the board; Prison or government entity federally authorized to possess prescription drugs

Repositories: Pharmacies

Patients: Indigent patient (person with an income < 600% of the federal poverty level); Uninsured; Underinsured; Can lastly go to another individual if an indigent, uninsured, or underinsured person is unavailable

Notes: Secure packaging. Recipient must have a valid Rx. No controlled substances. No REMS Drugs. No restriction of use of samples.

Vermont

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person or institution in Vermont (including pharmacies, long-term care facilities, VA, correctional facilities, hospitals)

Repositories: Pharmacies; Hospitals; Cancer centers; Long-term care facilities (nursing homes, residential care homes, assisted living facilities). Must be approved by VT DHHS first

Patients: One of the following: Under 400% of the FPL; Uninsured or underinsured; Be in the medicare ‘donut hole’ and/or have high deductible coverage, or high copays

Notes: No controlled or compounded drugs. No REMS drugs.

Utah

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Nursing care facility; Manufacturer; Wholesaler; Assisted living facility; An eligible pharmacy (licensed in UT as Class A retail or operated by county/health department, UT DHHS, or charitable clinic); Physician’s office; Intermediate care facility for intellectual disability

Repositories: Pharmacy operated by a charitable clinic

Patients: Medically indigent; Uninsured; Lack reasonable means to purchase prescribed meds; Insured (and lack reasonable means to pay the insured portion of the cost of prescribed meds)

Notes: No controlled substance or drugs that require registration with the manufacturer. Secure packaging. Cancer drugs may be dispensed in an unopened single unit dose that has been removed from a multi-unit dose pack.

Texas

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Patient; Manufacturer; Health care facility (hospital, ambulatory surgical center); Pharmacy; Family Member; Caregiver; Healthcare Provider
Donor must sign a form confirming (owner of donated drug, proper storage, voluntary)

Repositories: Health care facility; Pharmacy; Pharmacist employed by the facility or pharmacy that has elected to participate in the collection/redistribution of donated prescription drugs

Patients: Recipient with a valid prescription by a health care professional
(must acknowledge that the donor is not a pharmacist if the donor is an individual/manufacturer/health care facility; donor is known to the participating provider; accepting risk from accidental mishandling; releasing donor/participating provider/manufacturer from liability)

Notes: No controlled substance, REMS drugs. Must be unopened, sealed, temper-evident, unit-dose, single-dose (if unopened). May charge a handling fee up to $20 to a recipient.

Pennsylvania

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Healthcare Facilities; Pharmacy; Manufacturer; Wholesaler

Repositories: Pharmacies

Patients: Uninsured or underinsured with income below 350% of FPL

Notes: Secure packaging. Opened multi-dose pack okay if single-unit doses remain intact. Must have an expiration date later than “6 months after the date the drug will be restocked.” No controlled substances. Cannot require any temp other than room temp for storage. Cannot be a drug that is subject to restricted distribution by FDA.

Patient eligible for the Cancer Drug Repository Program that meet the following criteria: Dx with cancer, none or limited prescription drug coverage related to cancer Tx that prevent patient from obtaining therapy, or not eligible for State Medical Assistance Program for cancer Tx coverage.

Financial eligibility for Cancer Drug Repository Program: “Indigent patient” for the Cancer Drug Repository Program; income limits are based on prior year’s family income not to exceed 350% of the prior year’s Department of Health and Human Services Federal Poverty Income Guidelines for the appropriate family size

Ohio

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any pharmacy, drug manufacturer, or health care facility, or other person or government entity may donate or give drugs to a drug repository program. Any person or government entity may facilitate the donation or gift of drugs to the program.

Repositories: Ohio Pharmacy; Ohio Hospital; Ohio Nonprofit clinic

Patients: Ohio resident or currently resides in Ohio; Uninsured or underinsured; Meets any other eligibility requirements as determined by the program’s policy

Notes: Drugs must not be controlled substances, except for controlled substances in a long-acting or extended-release form used for treatment of opioid dependence/addiction. No drug samples. For orally administered cancer drugs not in original sealed and tamper-evident unit dose packaging: drugs must appear to be unadulterated, safe, and suitable for dispensing and must have an expiration date of “6 months or greater” (from day of donation).

New York

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person or entity

Repositories: Pharmacy Hospital or nonprofit clinic

Patients: Residents of NY based on economic need

Notes: Only prescription drugs in their original sealed and tamper-evident unit dose packaging

New Mexico

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Corrections facility with a registered or licensed nurse

Repositories: Clinic or licensed practitioner (authorized to prescribe drugs & registered with the board); Can only accept donation originally prescribed for use by established patients of that participating practitioner/licensed clinic

Patients: Any individual who signs a form acknowledging the drug donation process

Notes: No controlled substances or drugs with a REMS program requirement. Must be stored in tamper-evident container, has expiration date of 6 months or greater, no drug shall be re-dispensed more than one time. Handling fee not to exceed $20 charged to the recipient. Participating practitioners must register with the NM Board of Pharmacy. Donors to sign the Board approved Donor Form.

New Jersey

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person or entity that is properly licensed and authorized to possess prescription drugs (manufacturer, wholesaler, repackager, returns processor, third-party logistics provider, health care facility, correctional facility, pharmacy); “Health care facility” (physician’s office, hospital, outpatient clinic, FQHC, rural health clinic, clinic providing services under Ryan White HIV/AIDS Program, mental health center, VA)

Repositories: Pharmacist or other health care professional who is authorized by law to dispense over-the-counter drugs and prescription drugs

Patients: Prioritized to individuals who are indigent (below 250% of FPL), uninsured, or enrolled in a public health benefits program; Other individuals if prioritized patient population is not identified

Notes: No controlled or compounded drugs. No prescription drugs that require patient registration with the manufacturer. Redistributor can accept OTC, Rx, admin supplies from out-of-state donors. Redistributor can charge a handling fee to an eligible recipient.

Michigan

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Residents of an eligible facility (or the representative or guardian of a resident of an eligible facility); Manufacturers

Repositories: Pharmacy; Charitable clinic; Health professionals

Patients: Any state resident who is eligible for medicare/medicaid who otherwise has no health insurance

Notes: Drugs not accepted include expired Rx drugs, controlled substances, drugs that have been held outside of a health professional control where sanitation/security cannot be assured, or drugs that can only be dispensed to a patient registered with a drug’s manufacturer under FDA requirements

Idaho

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Pharmacy; Hospital; Nursing home; Drug manufacturers or wholesale distributors; Prescriber drug outlet

Repositories: Charitable clinics; Pharmacies; Regional behavioral health center

Patients: Qualifying medically indigent patients

Notes: No controlled substances (II-V). Cannot accept drugs with fewer than 3 months from its expiration date.

Connecticut

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Long-term care facilities

Repositories: Vendor pharmacy (for repackaging and reimbursement to the Department of Social Services)

Notes: No controlled substances. Oral/parenteral must be in single-dose containers. Inhalent/topical must be in unit-dose containers.

California

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Acute care hospital; Acute psychiatric hospital; Skilled nursing facilities; Intermediate care facilities (disabled-habilitative, disabled-nursing); Correctional treatment center; Psychiatric health facility; Chemical dependency recovery hospital; Residential care facilities (for elderly); Mental health rehab center; Juvenile facility; Local detention facility; Home health agency; Hospice agency; Pharmacy licensed in CA; Wholesaler licensed

Repositories: Licensed pharmacy (owned/contracted with county; operated by primary care clinic)

Patients: Indigent patients

Notes: No controlled substance. Medication shall not have been in the possession of a patient or any individual member of the public. Must have written/electronic documentation from the county health department to participate in the repository/distribution program.

Arizona

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any individual member of the public or any entity legally authorized to possess medicine (manufacturer, wholesaler, distributor, third-party logistic provider, pharmacy, dispenser, clinic, surgical center, health center, detention/rehabilitation center, laboratory, medical school, pharmacy school, health care professional or health care facility). Government agencies (drug manufacturer, repackager, relabeler, outsourcing facility, prisons, importers authorized by FDA).

Repositories: Physician’s office; Pharmacy; Hospital; Healthcare institution

Patients: Indigent, uninsured, underinsured, or enrolled in a public health benefits program

Notes: Prescription, non-prescription, biologics allowed

Wisconsin

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any individual over 18; Pharmacy; Medical facility; Manufacturer; Distributor

Repositories: Medical facility; Pharmacy

Patients: Any Wisconsin resident who is: Uninsured; Recipients of eligible recipients of Medicaid, Medicare, or other government based health care; All other individuals

Notes: Medical facility or pharmacy may charge an individual receiving a drug or supply a handling fee that may not exceed amount specified by department rule. Secure packaging. Drug bears an expiration date that is later than 90 days after the date donated. Donated drug or supplies cannot be resold. Recipient of donated drug or drug supplies must have valid Rx.

Wyoming

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Patient; Family Member; Caregiver; Healthcare Provider; Manufacturer

Repositories: Physician’s office; Pharmacies; Healthcare facilities

Patients: Eligible patients based on application info includes: Demographic info with income, number of people in household, and payment frequency of income; Prescription info with pharmacy info, prescriber info, and any known allergies to meds; Proof of income (or no income) and residency in Wyoming

Notes: Secure packaging. Redispensed drugs shall not be within 2 months of expiration date. Dispensed drugs must be in the donation program under the Medical Assistance and Services Act. Available drugs for redispensing are inventoried and listed on the department’s internet website.

West Virginia

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person or entity

Repositories: Pharmacy; Hospital; Health care institution

Patients: Indigent patients prioritized

Notes: No controlled substances or drugs subject to REMS programs

Washington

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Patient; Patient representative; Practitioner; Pharmacist; Medical facility; Drug manufacturer; Drug wholesaler

Repositories: Pharmacies

Patients: Priority give to uninsured patients

Notes: Secure packaging. Not a controlled substance.

Virginia

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Manufacturers; Wholesalers; Pharmacies; Oncology Centers; Individuals; Facilities; Hospitals

Repositories: Registered drug donation site

Patients: Indigent patients

Notes: Secure packaging. Drug bears an expiration date that is later than 90 days after the date donated. No controlled substances. No REMS program drugs. No compounded drugs.

South Dakota

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Pharmacies

Patients: “Eligible patient,” an indigent, uninsured, or underinsured person prioritized

Notes: Original, tamper-evident packaging

South Carolina

Donation & Reuse Laws: No

Operational Program: No

Rhode Island

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person or institution

Repositories: Redistributor: any person or institution partaking in redistribution

Patients: Uninsured, underinsured, or are reliant on public health programs

Notes: Can transfer drugs to other instate redistributors and out of state redistributors

Oregon

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Manufacturer; Wholesaler; Pharmacy; Medical clinic; Physician; Individual

Repositories: Charitable Prescription Drug Program

Patients: Charitable Prescription Drug Program eligible patients that are a state resident, underinsured or lack health insurance coverage for the prescription drug requested, or enrolled in a public assistance or a medical assistance program.

Notes: Program may accept and distribute within this state Rx drugs in original, sealed, tamper-evident packaging, displays lot number and expiration date. May not distribute donated Rx drugs that have an expiration date that is less than 9 months from the date the drugs are donated. No controlled substances that are under the program as adopted by the board by rule pursuant to ORS 689.774.

Oklahoma

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Nursing home resident; Guardian of resident; Representative of resident

Repositories: Pharmacy; Charitable clinic

Patients: Based on the economic needs of the person who will receive the prescription drug(s) under the Program. Patient has identification card showing they are eligible to receive donated prescription drugs under the Program.

Notes: Only Rx drugs in their original sealed packaging or unused injectables. No controlled substances.

North Dakota

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Contracted entities with state board of pharmacy

Patients: An eligible individual

Notes: Secure packaging. Opened multi-dose pack okay as long as single-unit doses remain in tact.

North Carolina

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Patient or family member; Manufacturer, Wholesaler; Pharmacy, free clinic, hospital, or hospice care program

Repositories: Pharmacy or free clinic holding a valid, current North Carolina permit

Patients: An uninsured or underinsured patient who meets the eligibility criteria established by the board, free clinic, or pharmacy

Nebraska

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Physician’s office; Pharmacy; Hospital; Health clinic

Patients: Eligible residents of Nebraska

Notes: Cancer drugs and immunosuppressants drugs only. Original, unopened packaging, except cancer drugs in single unit doses may be accepted if unopened.

New Hampshire

Donation & Reuse Laws: No

Operational Program: No

Notes: Repealed their reclamation law 09/01/23

Montana

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Any participating health entity

Patients: Any person who the board considers “qualified”

Notes: May accept cancer drugs if drug/device is in its original, unopened, sealed, and tamper-evident unit dose packaging. Cancer drug package in single-unit doses may be accepted if unopened.
Can’t accept expiration date earlier than 6 months after the date the drug was donated, consider adulterated or misbranded, or subject to restricted distribution pursuant.

Missouri

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person or entity

Repositories: Pharmacy; Hospital; Nonprofit clinic

Patients: Any person whose family income is 300% below the PFL

Notes: Donated drugs may be repackaged in a manner appropriate for distribution by participating pharmacies, hospitals, and nonprofit clinics

Mississippi

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person including a drug manufacturer, health care facility or government entity

Repositories: Pharmacy; Hospital; Nonprofit clinic

Patients: Any individual who meets states’ economic standards

Notes: Only drugs in their original sealed and tamper-evident packaging may be accepted and dispensed, except that drugs packaged in single unit doses

Minnesota

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person over 18 or entity

Repositories: Pharmacy; Medical facility; Nonprofit community clinic or FQHC

Patients: Any state resident that is uninsured or underinsured

Notes: Must be more than 6 months from expiration. No controlled substances or drugs that require storage temperatures other than normal room temps, unless donated directly by its manufacturer, wholesale drug distributor, or a pharmacy located in Minnesota.

Massachusetts

Donation & Reuse Laws: No

Operational Program: No

Notes: Bill 1208 in process, should know more by end of 2024

Maryland

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Pharmacy; Board approved drop-off sites

Patients: Any needy Maryland resident as indicated by resident’s practitioner

Notes: Must be in secure packaging. Donor must sign statement indicating ownership of drugs and voluntarily offering them to program. A repository may not establish a waiting list for any Rx drug or med supply dispensed by program. Cannot charge a dispense fee >$10.

Louisiana

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Charitable pharmacies

Patients: Appropriately screened and qualified patients

Notes: Secure packaging; HIPAA; No drug dispensed through a charitable pharmacy shall be eligible for reimbursement from Medicaid Pharmacy Program.

Maine

Donation & Reuse Laws: No

Operational Program: No

Kentucky

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Health facilities; Pharmacy

Repositories: Health facilities; Pharmacy

Patients: Indigent, uninsured, or underinsured; Other patients, if a need for the donated drugs is not identified among the above three

Notes: No controlled substances or samples

Kansas

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Adult care homes; Mail service pharmacies; General medical care facilities

Repositories: Qualified center or clinic

Patients: Any medically indigent resident

Notes: Must come from a controlled storage unit of donating entity. Must be in original or tamper-evident packaging. Drugs purchased under Medicaid or SCHIP do not apply. No controlled substances.

Iowa

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person over the age of 18

Repositories: Pharmacy; Medical facility

Patients: Any individual resident of Iowa who is indigent, has no 3rd party reimbursement coverage for the drug prescribed, receives income that doesn’t exceed 200% of FPL, acknowledges that the drug may be donated, or consents to waiver of child resistant packaging.

Notes: No controlled substances. No drugs that require storage temperature outside of room temp. No drugs that expire before completion.

Indiana

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Any person over 18

Repositories: Pharmacy; Wholesale drug distributor; Hospital licensed under IC 16-21; Health care facility; Nonprofit health clinic

Patients: Income < 200% FPL and is either uninsured or underinsured with no third party prescription drug reimbursement coverage

Notes: No controlled substances; No medicaid drugs unless product costs credited back to medicaid

Illinois

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Any person or entity legally authorized to possess medicine with a license or permit in the state

Patients: Indigent patients prioritized

Notes: No controlled substances

Hawaii

Donation & Reuse Laws: No

Operational Program: No

Georgia

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: Pharmacy; Hospital; Federally qualified health center; Nonprofit clinic

Patients: Medically indigent person; Uninsured/underinsured; Those enrolled in a public assistance health benefits program

Notes: Drugs must be in sealed original or tamper-evident unit dosed packaging. Drug must not expire before completion of medication for prescription and OTC meds. No controlled substances or REMS.

Florida

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Any person or entity

Repositories: A healthcare practitioner’s office; Pharmacy; Hospital; A nursing home facility; Free clinic or nonprofit healthcare clinic

Patients: State residents (indigent, uninsured, or underinsured) (Excluding those who are Medicaid eligible or those who are covered by prescription drug programs)

Notes: Must remain within shelf-life for redispensing purposes for pharmacist verification. State has a prescription drug donation repository program and a cancer drug donation program.

Colorado

Donation & Reuse Laws: Yes

Operational Program: Yes

Donors: Patient; Patient Relative

Repositories: Health Care Facility; Hospital; Pharmacy; Assisted living facility; Correctional facility; Hospice

Patients: Uninsured/underinsured patients; Patients below 250% poverty level

Notes: No controlled substances; Must be sealed in individual packaged units; Must be within shelf life for redispensing purposes
* Effective until July 1, 2024

Delaware

Donation & Reuse Laws: No

Operational Program: No

Alaska

Donation & Reuse Laws: No

Operational Program: No

Arkansas

Donation & Reuse Laws: Yes

Operational Program: No

Donors: Clinic pharmacies of nursing facilities

Repositories: Charitable clinic including licensed outpatient pharmacy

Patients: Patients below 200% poverty level

Notes: No controlled substances