A written protocol for a specific patient established pursuant to a collaborative drug therapy management agreement shall include, but need not be limited to, the following:

1. (1) The specific drug or drugs to be managed by the pharmacist;
2. (2) The terms and conditions under which drug therapy may be implemented, modified or discontinued;
3. (3) The conditions and events that the pharmacist is required to report to the physician;
4. (4) The laboratory tests that may be ordered by the pharmacist; and
5. (5) The drugs that may be administered by the pharmacist.

(Effective January 2, 2013)