Introduction and Background
Many states have expanded scope of practice laws to allow pharmacists to prescribe hormonal contraceptives as one in an array of strategies to increase access to contraceptives. States determine the scope of practice and services that can be delivered by licensed pharmacists through state law and regulations.
States have authorized pharmacist prescribing and administration of certain medications (e.g., Paxlovid, naloxone), vaccinations (e.g., pneumonia, COVID-19), and testing for acute health conditions (e.g. strep, influenza). States that allow pharmacists to prescribe contraceptives have authorized prescribing of one or more hormonal methods, including birth control pills, the patch, the ring, and/or injections.
State law delegates the regulatory and oversight authority of licensed pharmacists to a state agency, typically a state’s board of pharmacy or health department, which may use its regulatory authority to allow pharmacists to prescribe specified medications, including hormonal contraceptives. Pharmacist prescribing authority is often further defined in a standing order, statewide protocol, or collaborative practice agreement. State policies allowing pharmacists to prescribe select medications can improve access to preventive health care by eliminating the need for a clinical visit to obtain a prescription.
The Centers for Medicare & Medicaid Services (CMS) has issued guidance outlining state options to expand pharmacists’ scope of practice as one strategy for improving Medicaid beneficiaries’ access to medications, including contraceptives, that address priority public health issues.
How can pharmacist prescribing improve access to contraceptives?
Pharmacy-based preventive care services may improve population health by increasing availability of medications, screenings, vaccinations, and treatments for otherwise underserved communities. Pharmacist prescribing of hormonal contraceptives may be associated with improved medication adherence by reducing barriers to renewing prescriptions that can lead to a lapse in contraceptive use.
Common barriers to accessing contraceptives include challenges related to transportation, childcare, work schedules, and geographic location. Individuals may face additional barriers depending on their health insurance coverage, including access to a prescribing in-network provider. For individuals who select a hormonal contraceptive method, the ability to both receive a prescription and have the medication dispensed in one location can alleviate some of these barriers.
What are state options to authorize pharmacist prescribing?
State laws determine the agency with regulatory and oversight authority for pharmacist prescribing, which is typically the state board of pharmacy or health department. States set policies related to pharmacist prescribing through a statewide protocol, standing order, or collaborative practice agreement.
Statewide protocols permit pharmacists to prescribe specified medications to patients who meet pre-screening health requirements. Statewide protocols are typically issued by the state board of pharmacy. Under a statewide protocol, pharmacists are not required to consult a clinician prior to prescribing hormonal contraceptives to a patient. Statewide protocols may include training requirements for pharmacists, dispensing limitations, and referral requirements for further patient evaluation. For example:
Arkansas’ statewide protocol, developed by the Arkansas Board of Pharmacy, outlines the eligibility requirements for pharmacists who are permitted to prescribe and dispense hormonal contraceptives. The protocol includes the prescribing guidelines, including patient screening requirements, pharmacist-physician communication requirements, and contraceptive counseling guidelines.
Standing orders permit pharmacists to dispense medication based on the specified guidelines, which may include training requirements, referral requirements, and dispensing limitations. Standing orders are issued by state health agencies (e.g., Department of Public Health, Medicaid). Under a standing order, pharmacists are not required to consult a physician before prescribing and dispensing contraceptives to a patient. In most cases, a standing order allows pharmacists to dispense hormonal contraceptives to all individuals of reproductive age. Standing orders can only permit pharmacists to dispense contraceptives for certain populations (e.g., women ages 18–44, individuals 21 and older). For example:
Illinois’ standing order for hormonal contraceptives applies to all pharmacists that have completed an Accreditation Council for Pharmacy Education (ACPE) accredited training (Oregon State University; American Pharmacists Association) specific to prescribing hormonal contraceptives. Illinois’ standing order includes pharmacist training requirements, clinical referral requirements, dispensing guidelines, and patient counseling guidelines. This standing order was issued by the Illinois Department of Public Health.
Collaborative practice agreements (CPAs) permit pharmacists to voluntarily contract with another health care practitioner and assume responsibility for specific patient care functions (e.g., initiation, prescription, modification of a medication). The types of services allowed under a CPA vary across states and are determined by the state’s scope of practice laws for pharmacists. For example:
Montana allows pharmacists and physicians to voluntarily develop a CPA that authorizes the pharmacist to prescribe certain hormonal contraceptives. The CPA outlines the types of decisions the pharmacist can make without clinical consultation and allows the contracted clinician to override decisions made independently by the pharmacist.
Key Considerations for State Pharmacist Prescribing Policies
State pharmacist prescribing policies are complex and require consideration of federal and state laws and regulations related to insurance coverage, cost-sharing, payment, and provider training.
Pharmacist Reimbursement and Patient-Cost Sharing
Federal law requires that most public health insurance (Medicaid and the Children’s Health Insurance Program) and private insurance cover prescribed contraceptives with no cost-sharing for patients. Federal law does not require coverage of pharmacist consultations for public and/or private insurers. However, some states that have authorized pharmacist prescribing of hormonal contraceptives require pharmacists to provide a consultation to the patient before dispensing the prescription.
Pharmacists typically bill Medicaid under a patient’s pharmaceutical benefit, which reimburses pharmacists for medications dispensed and does not provide reimbursement for consultations. This can result in out-of-pocket costs for patients to cover the cost of a medication consultation provided by their prescribing pharmacist. To receive reimbursement for patient consultations under a patient’s medical benefit, prescribing pharmacists must be enrolled in Medicaid as a provider, credentialled by the state’s contracted Medicaid plans, and have an individual National Provider Identifier (NPI). However, many pharmacists currently operate under the NPI of the pharmacy they are affiliated with, posing barriers to submitting claims for individual pharmacist consultations.
Pharmacist Training Requirements
States that allow pharmacists to prescribe hormonal contraceptives have established training requirements that pharmacists must fulfill to practice the prescribing authority. Pharmacist training is typically overseen and approved by a state’s board of pharmacy or state health department.
California and North Carolina are among states that have a training program to support pharmacists to prescribe hormonal contraceptives. These trainings cover topics that include patient health and safety, administration of transdermal hormonal contraceptives, and billing for consultations. Other states with pharmacist prescribing authorities may refer pharmacists to a training course provided by a third party (e.g., Accreditation Council for Pharmacy Education (ACPE), Birth Control Pharmacist, American Pharmacists Association, and/or an academic institution).
Case Study: Improving Access to Contraceptive Care through Pharmacist Prescribing
Patient Health Requirements
States may require pharmacists to conduct a health screening or provide patients with a self-assessment prior to prescribing hormonal contraceptives, using the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria for Contraceptive Use. If a pharmacist determines that a patient is not eligible for hormonal contraceptives based on their health history, they may be required to refer the patient to a physician.
Physician Referral Requirements
States may require referrals to a primary care provider or obstetrician-gynecologist after a pharmacist prescribes contraceptives and prior to providing a renewed prescription. In states with physician referral requirements, patients typically must be seen by a physician within a specified time frame, ranging from six months to three years, before a pharmacist can renew the prescription. However, many states that authorize pharmacist prescribing do not require referrals to clinicians for pharmacists to continue prescribing hormonal contraceptives.
Acknowledgments
This explainer was written by Dakota Staren. Several NASHP staff contributed to the case study through input, guidance, or draft review, including Anna Lipton Galbraith and Karen VanLandeghem.
This work is made possible through generous support from Arnold Ventures.