Allowing pharmacists—an important resource and critical access point for care in communities—to both prescribe and dispense hormonal birth control could help mitigate barriers and expand access to contraception.
A growing number of states—more than 10 since 2020—have expanded or strengthened pharmacists’ prescriptive authority to include contraceptives. While many states are in the early implementation stages, some are already seeing promising results, including mitigated access barriers and decreased costs.
Common challenges to implementing pharmacist prescribing include pharmacist awareness and transparency, training and continuing education for pharmacists, adequate billing infrastructure and reimbursement, patient privacy and confidentiality, and concerns of safety and pharmacist liability.
Introduction and summary
An important policy strategy to expand and improve contraceptive access at the state level is to broaden pharmacists’ prescriptive authority so that they can not only dispense but also prescribe contraceptives. Currently, almost half of states allow pharmacists to do so. Many of these states have encountered significant implementation challenges, however, such as building sufficient billing infrastructure and reimbursing pharmacists for services, meeting privacy and confidentiality standards, and training pharmacists and updating protocols. Any effort to broaden pharmacists’ prescriptive authority must also address these issues for it to be effective.
As of the publication of this report, 24 states and Washington, D.C., allow pharmacists to prescribe hormonal contraceptives through a statewide protocol, standing order, or collaborative practice agreement (CPA).1 However, many states are in the early stages of implementation and have not finalized regulations yet, and a few specify under which circumstances pharmacists are allowed to prescribe contraception. Other states may find it illustrative to understand the experiences of these states, particularly those that were early adopters of prescriptive authority. For example, in 2016, California and Oregon became the first states to authorize pharmacists to prescribe contraceptives,2 with several other states soon following suit. Since 2020, more than 10 states have enacted or strengthened policies to allow pharmacists to prescribe contraceptives3—a sign of the increasing popularity of pharmacist prescribing as a way of expanding access to contraception.
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Widespread support for pharmacist prescribing of contraception
Pharmacies are an important resource and critical access point to health care, particularly in communities with limited access to primary care physicians.4 Pharmacists have an advantage in serving their communities due to their locations, extended hours, and lack of appointment requirements for consultations.5 In addition, convenient, consistent, and dependable access to contraceptive care through pharmacies increases the likelihood of longer-term continued and consistent contraceptive use; reduces the likelihood of unintended pregnancies; and, importantly, allows women to better plan their pregnancies.6
Patients and pharmacists overwhelmingly support pharmacist prescribing of contraceptives. Research demonstrates that the convenience and accessibility of pharmacies are driving factors in increasing the likelihood of pharmacy utilization to access contraceptive services. For example, one study in California found that 74 percent of respondents chose to visit a pharmacist for contraception because it would be faster than getting a doctor’s appointment.7 That same study found that 97 percent of patients reported overall satisfaction with pharmacist-prescribed contraception, and 96 percent reported they would return for services. Additionally, one study from 2009—several years before the first state implemented pharmacist prescribing—found that 85 percent of pharmacists who participated in a national survey expressed interest in being able to prescribe contraceptives.8
Benefits to pharmacist prescribing: Convenience and cost
As reflected in support for the policy, one clear benefit to pharmacist prescribing is that it eliminates the need for patients to first get a prescription from a physician, reducing logistical burdens and other barriers such as scheduling appointments, taking time off work, travel time, child care, and more.9 Pharmacist prescribing allows most people to make one stop at the pharmacy for contraceptive care. In addition, pharmacists are often more accessible than other health care providers, making contraceptive care visits less burdensome, particularly for those living in underserved communities, rural areas, and contraceptive deserts.10 Pharmacists are great community resources and are well-trained to offer the screening and testing required for contraceptive visits.11
Beside these clear patient benefits, pharmacist prescribing of contraceptives may be increasing in popularity12 because it is cost effective and may reduce other health care costs. Two years after Oregon implemented its pharmacist-prescribed contraception protocol, the policy prevented an estimated 51 unintended pregnancies and saved the state $1.6 million.13 The study also found that women’s quality of life improved, as determined by projected life expectancy and reported satisfaction with their health status (measured in quality-adjusted life years). The cost savings associated with making hormonal birth control accessible in pharmacies have been shown to exceed the costs.
Implementing pharmacist prescribing
States can employ three main legal and regulatory processes to expand pharmacists’ scope of practice to prescribe medications. These processes are not new; they can be used for medications other than contraceptives as well.
The first and least restrictive process is through a statewide protocol, also known as outright prescriptive authority. The National Alliance of State Pharmacy Associations (NASPA) defines a statewide protocol as “a framework that specifies the conditions under which pharmacists are authorized to prescribe a specified medication or category of medications when providing a clinical service.”14 In practice, this means that a protocol must detail the qualifications and procedures required for a pharmacist to prescribe contraceptives and other medications and vaccinations.15 Statewide protocols are authorized by a state regulatory body, often a state board of pharmacy. They do not require physician oversight,16 which typically makes them a valuable option for states looking to address specific public health access needs.17
The second and more restrictive process is through the completion of a collaborative practice agreement in partnership with other health care providers.18 CPAs are formal agreements between pharmacists and prescribers that authorize the pharmacist in “selecting, initiating, monitoring, continuing, and adjusting medication regimens” for patients.19 States may also introduce what is known as a statewide standing order, which can operate like a statewide protocol or CPA depending on its details.20
Generally, statewide protocols are preferred to standing orders and other agreements.21 This is mainly because a statewide protocol applies to all pharmacists across a state rather than just a select group or few who have entered into a CPA. Statewide protocols could also have broader applicability and be better positioned to address gaps in contraceptive care and a state’s public health needs more broadly.
In 2016, NASPA and the National Association of Boards of Pharmacy (NABP) convened a working group of experts to create recommendations22 for states looking to develop and implement a statewide protocol for pharmacist prescribing. The working group advised that a phased approach be taken to developing a protocol. It also made the following specific recommendations: 1) Initial state legislation that authorizes pharmacist prescribing “should be general” so that certain medications can be determined and specified under the regulatory process after legislation is passed; 2) The state board of pharmacy should be the regulatory body authorized to issue a statewide protocol; 3) Statewide protocols should not cover the roles or “delegation to non-pharmacist staff”; 4) Statewide protocols should not cover the practice setting, meaning they should not limit or explicitly define what type of pharmacy is included under the protocol; 5) Core components of statewide protocols should include the covered medications or categories of medications, pharmacist training and qualifications, and operational procedures; and lastly, 6) Statewide protocols should ensure that payment mechanisms and insurance coverage are adequate for services.
Case studies: Approaches to implementing pharmacist prescribing
Although pharmacist-prescribed contraception laws vary from state to state, most of them cover two or three hormonal contraceptive methods.23 All states that allow pharmacist prescribing cover birth control pills. Most states also cover monthly birth control patches and rings. A few states cover injectable hormones and other self-administered methods approved by the Food and Drug Administration (FDA). The following case studies are not designed to be comprehensive—and the Recommendation section below describes some additional statistics from states to further explain the need for certain changes—but they demonstrate some notable trends in implementation.
In 2017, Hawaii became the sixth state to extend pharmacist prescriptive authority to contraception,24 passing and enacting Act 067, S.B. 51325—a statewide protocol allowing pharmacists to “prescribe and dispense” hormonal contraceptives.26 The purpose of this protocol “is to expand access to prescription contraceptives by: (1) Authorizing pharmacists to prescribe and dispense self-administered hormonal contraceptive supplies; and (2) Specifying requirements pharmacists must meet prior to prescribing and dispensing contraceptive supplies.”27
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Some experts have emphasized the critical importance of Hawaii’s action in giving pharmacists this authority given the state’s ongoing shortage of health care providers, which the COVID-19 pandemic has only exacerbated.28 The law requires pharmacists who prescribe and dispense contraceptive supplies to complete an Accreditation Council for Pharmacy Education program; provide patients with a self-screening risk assessment tool; refer patients to their primary care providers upon prescribing and dispensing contraceptives or conducting consultations; give patients a written record of the contraceptives prescribed and dispensed; and dispense the contraceptives to patients “as soon as practicable” after prescribed.
In a survey of 175 pharmacies in Hawaii, researchers found that only around 30 percent offered pharmacist-prescribed contraceptives, with variability across geographic areas.29 When researchers asked the remaining pharmacies why they did not offer pharmacist-prescribed contraceptives, the primary reasons cited were lack of training and knowledge about the new protocol.
Additionally, although insurers are required to cover the cost of the full range of FDA-approved contraceptive products under the Affordable Care Act (ACA),30 70 percent of pharmacies surveyed still charged patients for the cost of a consultation (averaging $35), which introduces a new payment barrier to patients. The researchers concluded that a key reason pharmacists charged a consultation fee was that they lacked a mechanism to receive insurance company reimbursement for consultation services.31
In 2015, Oregon was the second state to permit pharmacists to prescribe self-administered hormonal pill and patch contraceptives, through H.B. 2879.32 The bill allows individuals to initiate or continue contraceptive care with a pharmacist; until January 2020, patients were required to have evidence of a previous prescription from a primary care provider for a birth control patch or an oral contraceptive.33 Additionally, in 2017, Oregon enacted H.B. 2527,34 which allows pharmacists to prescribe and administer injectable hormonal contraceptives and to prescribe and dispense self-administered hormonal contraceptives. The law also requires insurers and health benefit plans to reimburse pharmacists for clinic visits and consultations.35
To implement the protocol, the Oregon Board of Pharmacy convened a work group of representatives and stakeholders, including pharmacists, pharmacy administrators, obstetricians and gynecologists, policymakers, and subject-matter experts to advise it on developing standard procedures for pharmacists’ prescribing hormonal contraceptives, in alignment with existing guidance for contraceptive use.36 In December 2022, the board adopted new rules37 to move pharmacist prescribing processes to a new advisory committee, the Public Health and Pharmacy Formulary Advisory Committee, which go into effect in February 2023.38 To participate in the program, pharmacists must complete a five-hour online training module that covers general information on contraception, medically necessary screenings, and referrals. The work group also created a process to refer women who were “unable to access care in pharmacies due to cost and medical contraindications.”39
Similar to Hawaii, Oregon experienced financial barriers and consultation cost challenges in the early phases of its program.40 The 2017 legislation helped mitigate some of those issues, but while the research suggests that pharmacists are willing to and interested in prescribing contraceptives, the actual uptake and prescribing practices still have room to grow.41 In 2020, 46 percent of pharmacies participated in pharmacist prescribing of contraceptives.42 Although this participation rate is higher than in other states, it still demonstrates a pronounced gap in pharmacist-provided prescription contraceptive services. Additionally, a differences-in-differences analysis found that the policy had no significant effect on increasing utilization of contraception in Medicaid-insured women.43 The authors suggest that as implementation is scaled up and availability of pharmacist-prescribed birth control increases, perhaps it will have more substantial effects on utilization and its benefits.
Charting a path forward
Nearly half of states across the country have moved to enact pharmacist prescribing of contraceptives, but many are still in their early implementation phases.44 In addition, states vary in terms of what they allow pharmacists to do and pharmacists’ scope of practice when prescribing hormonal contraceptives based on the designated prescriptive authority.45 In addition to some of the issues described above, pharmacist prescribing of contraceptives comes with a number of individual, community, and system-level challenges that state policymakers and regulatory agencies have sought to address, some with more success than others. Overall, research has identified the following main factors as challenges to pharmacist prescribing: pharmacist awareness, training, and education; safety concerns and patients forgoing recommended check-ups and health screenings; and cost, billing, and reimbursement.46
However, most pharmacists and other health care providers support pharmacist prescribing of contraceptives and recognize the significant benefits to improving access. As previously noted, pharmacists are “the most accessible health care provider[s], offering convenient locations and extended hours of operation.”47 In addition, researchers note that pharmacist-prescribed contraceptive services help improve pregnancy outcomes, increase contraceptive regimen adherence and continuation, and minimize costs. A 2008 survey in Washington state found that 70 percent of women reported continued use of their pharmacist-prescribed contraceptive method after 12 months and almost every respondent “expressed willingness to continue to see pharmacist prescribers” for contraceptive services.48
Common challenges to implementing pharmacist prescribing and recommended solutions
Challenge: Awareness and transparency
Like many new policies and statewide laws, one recurrent challenge is for policymakers and regulatory bodies to develop an outreach strategy and process for disseminating new information. This goes for educating both the general public and health care professionals such as primary care providers and pharmacists. To address this implementation barrier, policymakers should consider taking the following actions:
- Create a robust alert and notification system to increase awareness of new policies and laws. Such information dissemination would include email alerts and notifications that contain printable, informational fliers and copies of the new policies.
- Develop a public and readily accessible list of all pharmacists and pharmacies that are certified to prescribe and dispense contraceptives. For example, Washington, D.C., requires that its pharmacy board “maintain a list of all pharmacists certified to prescribe and dispense contraception, including the location of the pharmacy where the pharmacist currently practices, and make that list readily accessible to the public.”49 It also requires pharmacies to “display in stores and online a list of the times during which a pharmacist certified to prescribe and dispense contraception is available.”50
Additionally, the Maryland Board of Pharmacy consulted with other state agencies and organizations to develop its pharmacist prescribing regulations. The board engaged with key stakeholders, “including the state Medicaid agency and department of insurance, and hired a third-party facilitator to support cross-stakeholder implementation planning meetings.”51 The board held “five stakeholder working sessions between July 2017 and September 2017 to determine the design” of its program prior to the regulations going into effect.52
Challenge: Formal training and education for pharmacists
Training programs and continuing education initiatives are imperative for a well-implemented policy that is responsive to people’s needs. Trainings may help pharmacists learn about or broaden their knowledge of hormonal contraception, including how to assess if a person meets eligibility criteria for use, how to communicate and conduct contraceptive counseling, and what operational changes and practices need to be in place to meet state standards. While not an exhaustive list, these components are crucial for implementing pharmacist prescribing of contraceptives. Another often overlooked component, which will become even more important as pharmacists’ authority and roles expand, is ensuring that pharmacists are incentivized to complete necessary trainings through continuing education credits and other means that compensate them for their time. States should:
- Create an implementation work group or other multidisciplinary task force to oversee and help with implementation and to issue training guidance. The Oregon task force, in addition to overseeing implementation, placed an emphasis on training pharmacists in contraceptive counseling, particularly the efficacy of certain methods and referral information for longer-term methods.53 Pharmacist participation in the program was voluntary, and prior to prescribing contraception, pharmacists who elected to participate completed a five-hour online training module.54
- Develop certification standards and incentivize pharmacists to complete continuing education around the statewide protocol. States may wish to look at other training models to inform the development of their pharmacist prescribing training. Maryland, for example, has an easily accessible online home training program55 to educate pharmacists and pharmacy technicians on prescribing contraception. The program offers three hours of continuing pharmacy education (CPE) credit and includes a review of contraception methods, “protocol procedures, patient education, service implementation, resources for both pharmacists and patients, and payment for pharmacist services.”56
National survey data show that nearly 60 percent of community pharmacists in the United States believe that pharmacists are well-trained to prescribe contraception.57 In the same survey, researchers found that pharmacists who did not receive hormonal contraceptives training through their pharmacy school curriculum felt less equipped to prescribe contraception, suggesting that formal training would help pharmacists feel adequately trained and competent to provide this service.
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Challenge: Billing and reimbursement
Another major concern is that pharmacists will not be able to receive reimbursement from insurers and health benefit plans for the additional labor and protocol required to prescribe contraceptives. Similar concerns have arisen in states that have increased access to contraception through one-year prescribing laws.58 Pharmacies may be reluctant to participate in contraceptive prescribing programs due to the lack of reimbursement for services that fall outside of physical dispensing of a drug—for example, cognitive services and counseling.59 Research demonstrates that pharmacists may be more likely to seek certification to become contraceptive prescribers—and, thereafter, to prescribe contraceptives—if they know they will be reimbursed for providing the service.60 Moreover, reimbursement may require pharmacists to submit additional paperwork to enroll as a billable provider.61
To address these concerns, states should:
- Develop billing guidance for pharmacists, as they are increasingly providing important care services, and train pharmacists on the guidance.
- Ensure that policies clearly require reimbursement for time spent and services provided, including contraceptive counseling.
- Develop and implement billing codes for pharmacists, where applicable.
New Mexico, Maryland, and Hawaii all offer good examples of how to ensure that pharmacists are paid for the time they spend on prescribing not only contraceptives but also other related services:62
- New Mexico requires plans to reimburse any participating pharmacist who is certified to prescribe contraceptives at the same rate provided to other health care providers.
- Hawaii requires pharmacists to be reimbursed for “medical services intended to promote the effective use of contraceptive supplies or devices to prevent unwanted pregnancy.”63 Some insurers have also implemented billing codes that pharmacists can use.
- In Maryland, after pharmacists enroll in the state’s Medicaid pharmacist prescriber program, they can bill for conducting a “patient assessment” to determine if a patient is eligible for contraception, and if so, which contraceptive to prescribe. To be reimbursed, pharmacists must complete and bill through a 1500 form from the Centers for Medicare and Medicaid Services.64
Challenge: Patient privacy and confidentiality
Another challenge concerns pharmacies having the space and capacity to provide patients the confidentiality necessary to adhere to state and federal privacy standards. This is one of the most crucial aspects to address in order to ensure that sensitive patient health information is protected and that patients have consented to treatment and are comfortable.
- Configure pharmacy spaces to create private areas for patients to receive counseling and discuss other protected matters with the pharmacist. One cross-sectional survey65 of community pharmacists in San Francisco found that lack of privacy was a consistent barrier to patients accessing pharmacist-provided contraceptives. Respondents noted that private care rooms and consultation rooms were an advantage. Private rooms provide space to conduct confidential health screenings and consultations, as well as sitting areas for more accurate blood pressure readings. All responding pharmacies that did not have a private room mentioned the need for one.
Patient privacy is a feature of California’s pharmacy law.66 According to the legislation, “All pharmacists furnishing self-administered hormonal contraception in a pharmacy or health care facility shall operate under the pharmacy or facility’s policies and procedures to ensure that patient confidentiality and privacy are maintained.”
Challenge: Concerns of safety and pharmacist liability
Last are concerns about patient safety and pharmacist liability. Certain medical conditions make some hormonal oral contraceptives inappropriate or unsafe for some individuals; this is known as contraindication. Without proper and thorough health screenings by a pharmacist and/or with incomplete disclosure of medical history from a patient, a person may be inappropriately prescribed hormonal contraceptives. To address the challenge of pharmacist liability in these cases, NASPA and the NABP recommend that states looking to introduce pharmacist prescribing do so under a statewide protocol rather than a CPA or standing order. This is because of concern with the “liability that may fall upon the single prescriber who issues a statewide standing order or statewide CPA which may serve as a deterrent to uptake.”67
To mitigate risk to patient safety, pharmacists, just like other health care providers, must perform the required patient screening and assessment, including a blood pressure screening, prior to a patient being prescribed hormonal contraceptives. The patient must also complete a screening questionnaire to determine eligibility. The questionnaire would be similar to one’s routinely used at a doctor’s office.
- Research demonstrates that pharmacists are overwhelmingly comfortable measuring blood pressure and confident in prescribing hormonal contraceptives based on those results.68 If pharmacists are unable to prescribe a drug, most policies require them to provide patients a referral to a different health care provider.
- Research shows that there is a relatively low error rate for pharmacists prescribing contraception, similar to the rates for other methods such as telehealth prescribing. Further, pharmacists have been shown to have the same error rate as primary care physicians: from 5 percent to 7 percent.69
- Studies show that patients are largely accurate when sharing information about their medical histories and completing screening questionnaires, suggesting that these concerns may be overstated.70
Pharmacist prescribing is an excellent step toward mitigating significant barriers to accessing contraception. However, to be most effective, pharmacist prescribing must be combined and work in conjunction with other policies to expand contraception access. For example, states—such as California, Oregon, and Washington—that have invested in one-year prescribing efforts and expanded pharmacist prescribing authority have seen significant improvement in contraceptive health care access, reductions in unintended pregnancies, and decreased spending and strain on their health systems. Allowing and supporting more pharmacists to prescribe birth control provides another important access point for women.71
The author would like to thank Osub Ahmed, Bela Salas-Betsch, Amina Khalique, Elyssa Spitzer, Maggie Jo Buchanan, and Tracy Weitz for their contributions to and reviews of this series.