Prescriptive Authority for Pharmacists: Oral Contraceptives

More pharmacists are pushing for prescriptive power, resulting in the enactment of new legislation in several states.

The biggest change seen in legislation regarding pharmacists’ prescribing authority recently has been in the availability of pharmacist-prescribed contraception. As a result, patients in certain states can obtain from select pharmacies different forms of birth control, including injections, patches, rings, and tablets. Six states have passed such legislation: California, Colorado, Hawaii, Maryland, New Mexico, and Oregon.^1,2 Several other states, including Illinois, Minnesota, Missouri, and New Hampshire, are considering legislation.²

The states that have enacted legislation most recently are Hawaii and Maryland. At press time, pharmacists in Maryland were awaiting regulatory action to authorize the prescription of birth control. The state’s board of pharmacy had until September 2018 to create guidelines and regulations. Following that, pharmacists will be able to write prescriptions starting in January 2019.³ The passing of legislation in Hawaii is more significant to health care access than in other states, given the continuing physician shortage on the islands.⁴ The principal benefit that health care providers in Hawaii hope to see from this is how pharmacists’ prescribing power can bridge the gaps in patient access to health care.

Although the new legislation improves access to care, certain steps must be taken to ensure that patients are appropriately assessed and approved for medication. Each state that has passed legislation requires patients to complete a questionnaire as a means of screening for appropriate candidates. Topics include blood pressure, medical, and medication history, pregnancy history and status, and smoking history. After completing the screening process, the pharmacist may decide to either issue the patient a prescription for birth control or refer her to a physician.

Because authority to prescribe is a state-level scope-of-practice issue, the requirements for pharmacists vary by state. For example, Oregon requires that the patient complete a questionnaire and receive regular blood pressure screenings. The patient must be 18 years or older or have had a previous prescription dispensed for contraceptives. The pharmacist can prescribe for 12 upcoming months at once. Pharmacists are required to take a 5-hour course to prepare them for assessing patients.⁵ Colorado also has a required questionnaire and an algorithm for determining eligible patients 18 years and older. In addition, pharmacists must take a continuing education course on contraceptives accredited by the Accreditation Council for Pharmacy Education.⁶ California has a self-screening tool that is evaluated by the pharmacist and requires the patient to have a blood pressure screening at that visit. Each pharmacist who wishes to participate must complete 1 hour of contraceptive-specific continuing education.⁷ All states require that pharmacists recommend regular clinic visits, provide the patient with educational materials, and document the encounter.

Some states have also adopted reimbursement requirements for pharmacists who participate. In California, insurance companies are not required to reimburse pharmacists for this service. However, pharmacies can charge an administrative fee of up to $10 above the retail price of the selected contraception drug therapy.⁸ Furthermore, California passed additional legislation that requires its Medicaid program to reimburse pharmacists for their services by July 2021.⁹ The legislation in place in Hawaii cites that reimbursement will be given to the prescribing and dispensing pharmacists.¹⁰

Despite the obvious improvement in access to care, there are obstacles to implementing these new laws. Even though the new legislation allows pharmacists to issue birth control prescriptions, it does not require them to do so. Participation is a key element in increasing access to contraception. In a cross-sectional study in Oregon, investigators concluded that shortage of pharmacy staff, liability concerns, and training requirements were the largest barriers to pharmacist participation.¹¹ One year after legislation was passed in California, a telephone survey was conducted to evaluate how many pharmacies had adopted the new practice. The conclusion was that “pharmacist-prescribed contraception was available in 11.1% of pharmacies.”¹²

As prescriptive authority continues to evolve in the world of pharmacy, these types of changes make implementing new legislation possible. Laws that keep developing and whose policies are incorporated into practice will allow the profession to expand and better serve patients. Although there will be barriers and battles to overcome, the policy that emerges will be all the better for them. Prescribing birth control is a major step in pharmacists’ ability to take some workload off physicians, use their knowledge to the fullest, and enhance the patient’s health care experience. Gauging the success of this can be a springboard for more prescriptive power for pharmacists, which is a huge goal when implementing new legislation. Action and policy coinciding to better serve the community is what gives this profession a great sense of purpose.

For more on this topic, view the video below.

Kelly A. Sarna and Mayce N. Vinson are PharmD candidates at the University of Kentucky College of Pharmacy in Lexington. Joseph L. Fink III, BSPharm, JD, DSc (Hon), FAPhA, is a professor of pharmacy law and policy and the Kentucky Pharmacists Association Endowed Professor of Leadership at the University of Kentucky College of Pharmacy.

References

• Pharmacists in Hawaii will now be able to prescribe birth control. National Alliance of State Pharmacy Associations website. naspa.us/2017/07/pharmacists-hawaii-will-now-able-prescribe-birth-control/. Published on July 24, 2017. Accessed September 20, 2018.
• Pharmacists authorized to prescribe birth control in more states. National Alliance of State Pharmacy Associations website. naspa.us/2017/05/pharmacists-authorized-prescribe-birth-control-states/. Published on May 4, 2017. Accessed September 20, 2018.
• Dresser M. Assembly gives OK for Maryland pharmacists to write birth control pill prescriptions. Baltimore Sun. April 8, 2017. baltimoresun.com/news/maryland/politics/bs-md-pharmacists-pill-20170408-story.html. Accessed September 20, 2018.
• University study finds Hawaii’s doctor shortage worsening. U.S. News & World Report. September 26, 2017. usnews.com/news/best-states/hawaii/articles/2017-09-26/university-study-finds-hawaiis-doctor-shortage-worsening. Accessed September 20, 2018.
• Oregon pharmacists prescribing of contraceptive therapy. Oregon Board of Pharmacy website. oregon.gov/pharmacy/Pages/ContraceptivePrescribing.aspx. Accessed September 20, 2018.
• Colorado State Board of Pharmacy approved statewide protocol for prescribing hormonal contraceptive patches and oral contraceptives. State of Colorado Department of Regulatory Agencies. drive.google.com/file/d/0B-K5DhxXxJZbNl80aFVwWjJmbk0/view. Accessed September 20, 2018.
• Board of Pharmacy, proposed legislation. California State Board of Pharmacy website. pharmacy.ca.gov/laws_regs/1746_1_pt.pdf. Accessed September 20, 2018.
• SB-493 Pharmacy Practice, California State Legislature (2013-2014).
• AB-1114 Medi-Cal: Pharmacist Services (2016).
• SB513SD1 HD2CD1 Relating to Contraceptive Supplies, Hawaii State Legislature (2017).
• Rodriguez MI, McConnell KJ, Swartz J, Edelman AB. Pharmacist prescription of hormonal contraception in Oregon: baseline knowledge and interest in provision. J Am Pharm Assoc (2003). 2016;56(5):521-526. doi: 10.1016/j.japh.2016.05.003.
• Gomez AM. Availability of pharmacist-prescribed contraception in California, 2017. JAMA. 2017;318(22):2253-2254. doi: 10.1001/jama.2017.15674.