Olivia C. Welter, PharmD
For nearly a decade, pharmacists in select jurisdictions have been able to prescribe hormonal contraceptives, and nearly every year, more states pass legislation granting pharmacists this authority.
A June 2023 survey published in the Journal of Women’s Health found that roughly 71% of women aged 18 to 44 years said they were interested in pharmacy-based contraception.
But there’s a lot for pharmacists to keep up with in this arena. Recent developments, including an OTC birth control pill, have started shaking up the world of contraceptives.
How can pharmacists best put birth control services into practice in today’s world?
Birth control goes OTC
In July 2023, FDA approved Opill (norgestrel 0.075 mg), the nation’s first hormonal contraceptive available over the counter. Opill’s manufacturer, Perrigo, annouced its first shipments of Opill to pharmacies and retailers nationwide in March 2024. A one-month supply is estimated to cost $20, while a 3-month supply is estimated at $50. Pharmacies will be able to set their own price for Opill when it hits pharmacy shelves.
Opill is a progestin-only birth control pill, meaning it doesn’t have an estrogen component like many prescription contraceptives. Sometimes referred to as minipills, progestin-only pills require more diligence than combination pills. According to Mayo Clinic, if the patient skips a pill or takes one more than 3 hours later than their scheduled time, a backup form of contraception must be used for at least 2 days.
Although Opill will be available over the counter for anyone who would like to purchase it, pharmacists should plan to offer counseling to ensure patients are aware of the need for a consistent routine in taking the medication. Progestin-only pills are good options for individuals who have high BP, are overweight, are 35 years or older, smoke tobacco, or have a history of blood clots or breast cancer.
Another manufacturer, Cadence, is currently working to gain FDA-approval of an OTC combination pill called Zena (ethinyl estradiol 0.02 mg and levonorgestrel 0.1 mg). If approved, Zena would be the first birth control pill containing an estrogen component available without a prescription. This would further increase access for individuals who prefer to take a combination pill rather than a progestin-only pill.
Pharmacists as prescribers
Currently, 29 states allow pharmacists to prescribe hormonal contraceptives. To make an informed decision, pharmacists will usually need to take a patient’s BP, discuss the patient’s goals for birth control, and conduct a full medical history to evaluate for any contraindications if the patient is receiving estrogen-containing pills. Because many states don’t allow pharmacists to bill for their time performing these patient care services when a prescription is given, the cost is typically passed on to the patient.
It remains to be seen whether insurance will cover Opill. Most insurance policies typically won’t cover OTC products, which means patients would need to pay cash for Opill. If they have a prescription, the pharmacy is able to bill insurance. On the other hand, if a patient gets that prescription from a pharmacist, the pharmacy may charge a service fee—typically anything from $30 to $50 to the patient. Does the patient want to pay the OTC price or pay for a consultation to get a prescription? Either way there will likely be an out-of-pocket cost associated.
In other cases, due to lack of reimbursement for services, many pharmacies opt out of providing birth control services even if their state allows it. One example is Tennessee. Although legislation passed allowing pharmacists to prescribe birth control under a collaborative practice agreement, the law states that pharmacies may not require patients to pay an administrative fee for the service if they use insurance to cover their prescription. Most patients opt to use their insurance if they have it, which means the pharmacy will only get paid for the cost of the medication and not the time spent performing the consultation.
Pharmacy resources
Despite these hurdles, many pharmacists still choose to offer patients birth control services and there are several strategies pharmacies can consider for putting these services into place.
According to a study published in the January/February 2024 issue of JAPhA, researchers found that most of the interviewed pharmacists in San Francisco said they were successful in implementing birth control services when they established company protocols, had advertising strategies, and employed pharmacists who were interested in furnishing birth control services to increase patient access. Some specific advertising strategies listed by pharmacists were banners in the pharmacy, advertisement on their website, and flyers at the pickup window. Pharmacists also noted that demonstrating ease of access to patients was an effective method for demonstrating the value of the service to patients.
For pharmacists looking for direct resources, the Birth Control Pharmacist website houses resources to help pharmacies feel prepared to offer a new birth control consultation program.
Pharmacists should also consult their state’s Board of Pharmacy rules to ensure they are following all regulations required for prescribing birth control. State pharmacy associations are also knowledgeable about state-level regulations and can share more information with pharmacy professionals who are interested in learning more about implementing a birth control prescribing service in their practice. ■
Shaping the future of hormonal contraceptive care
On February 28, 2024, APhA and the Contraceptive Access Initiative (CAI) concluded the Accessible Consumer Choices: Shaping the Future of Contraceptive Care at Pharmacies Summit. The summit convened a diverse range of private and public sector partners, including representatives from the White House Gender Policy Council, HHS, pharmacy businesses, pharmacists, patient advocates, and other influential voices. Throughout the day, participants engaged in fruitful discussions, collaborative sessions, and strategic planning aimed at advancing accessible and equitable hormonal contraceptive care at pharmacies.
“By addressing barriers and fostering collaboration, we are making significant strides in ensuring patients have broader access to essential health care services provided by pharmacists,” said Michael D. Hogue, PharmD, FAPhA, FNAP, FFIP, APhA’s executive vice president and CEO.
Participants identified federal and state policy barriers and implementation obstacles that currently limit patient access to pharmacist-provided hormonal contraceptives and worked together to develop recommendations aimed at overcoming policy and implementation barriers, ultimately increasing access to pharmacist-provided hormonal contraceptives.
Partnerships between the public and private sectors as well as between patient advocacy groups and the pharmacy community were fostered to collectively address and overcome existing barriers and ways in which to increase public awareness regarding pharmacist-provided hormonal contraceptives as a viable and accessible option to meet reproductive health care needs were discussed.
“Through our partnership with APhA on this convening and with the thoughtful expertise of every participant, we have identified significant areas of common interest,” said Dana Singiser, partner at Keefe Singiser Partners and CAI cofounder. “We look forward to continuing our work toward making contraception truly available and accessible to all.”
The summit’s outcomes and recommendations will be compiled into a comprehensive report, which will be made available to the public and policymakers. ■