Can a Pharmacist Prescribe Medications? Know the Regulations

Can a Pharmacist Prescribe Medication?

Pharmacists in the United States are able to prescribe certain medications. However, their authority to prescribe all medications is limited to state-specific regulations and protocols. Continue reading to understand when pharmacists can prescribe medications, the regulations surrounding prescriptive authority, and the benefits.

Understanding Prescriptive Authority

Pharmacists are known as the most accessible healthcare providers in the U.S. and abroad. According to a 2020 study, 90% of Americans live within 2 miles of a pharmacy. This means that pharmacists' role in patient care is gradually expanding to increase their ability to prescribe (or prescriptive authority) to increase access to care and thus improve patient outcomes.

However, there are restrictions. Pharmacists can indeed prescribe and perform certain clinical services, but only those designated by state protocols or collaborative practice agreements (CPAs).

Regulatory Boundaries and Scope of Practice

Pharmacists can prescribe medications directly or collaboratively through the following modalities:

Collaborative Practice Agreements (CPAs) establish a formal relationship between a pharmacist and a healthcare provider (physician or other providers such as nurse practitioners) in which the provider delegates the authority for a pharmacist to prescribe certain medications or perform certain clinical services. These types of agreements are more common in clinical settings where pharmacists are able to closely monitor and manage patients with chronic conditions or diseases. Under a CPA, a pharmacist can initiate, modify, or discontinue medication while managing chronic conditions. CPA’s also allow pharmacists to authorize refills and order blood tests.

CPAs can be patient-specific or population-specific. Patient-specific CPAs allow pharmacists to prescribe to patients listed in the agreement. On the other hand, pharmacists are authorized to prescribe to a certain patient population described in the agreements.

Statewide Protocols allow pharmacists to prescribe specific medications independently, without the supervision of a physician, and directly to patients. Statewide protocols outline the required qualifications and guidelines for the pharmacist. Typically, statewide protocols are put into place to tackle common public health issues and to care for patients who do not require a new diagnosis. Statewide protocols have been implemented in several states for hormonal contraceptives, smoking cessation therapies, immunizations, naloxone for opioid overdose, and others.
Statewide Standing Orders are protocols or standard guidelines that grant pharmacists and other qualified healthcare professionals (i.e., nurse practitioners) the permission and authority to administer medications or vaccinations after a comprehensive assessment of the patient and their medical needs. However, the standing order is required to be approved by a physician, medical director, or authorized practitioner before any medication can be administered.
Class-Specific Prescribing/ Category-Specific Prescribing is when a state allows pharmacists to prescribe a class of medications without a statewide protocol, granting pharmacists to use their clinical judgment and practice more autonomy.

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State-by-State Regulations

The level to which pharmacists can prescribe varies, and in some states, pharmacists have a less restrictive prescribing authority than others. For instance, pharmacists in California, Idaho, and New Mexico can independently prescribe medications for conditions like uncomplicated urinary tract infections (UTIs), while some states only allow pharmacists to prescribe a limited amount of medications under a CPA. Check your Board of Pharmacies website for more detailed restrictions for your particular state.

Comparison of Prescriptive Authority Across States

Most states have limited pharmacist prescribing capabilities and may only allow for birth control, naloxone, and/or vaccinations to be prescribed by a pharmacist.

There are several states with growing capabilities to prescribe, such as New Mexico, California, Ohio, Massachusetts, Oregon, Idaho, New York, Iowa, Montana, North Carolina, and Florida.

Montana and North Carolina allow pharmacists advanced practice licenses under a CPA and protocol to have prescriptive authority over all patient drug therapies, including controlled substances.

For Example, Idaho is less restrictive than Nevada: Idaho vs. Nevada

What can pharmacists prescribe in Idaho?

Licensed pharmacists are given expanded prescribing capabilities in Idaho, allowing them to prescribe the following category-specific medications independently:

Medications for minor conditions: Lice, cold sores, motion sickness prevention, uncomplicated urinary tract infections
Devices: inhalation spacer, nebulizer, diabetes blood sugar testing supplies, pen needles, and syringes
Antimicrobials if a symptomatic patient tests positive on clinical laboratory improvement amendments (CLIA-WAIVED tests): Influenza, group A streptococcal pharyngitis
FDA-approved drugs such as statins like atorvastatin and short-acting beta-agonists (SABA) like albuterol for patients with asthma
Emergency drugs like epinephrine
Antihistamines, such as diphenhydramine
Medications for Lyme disease prevention
Travel medications
Medications to supplement an infusion order

What Can Pharmacists in Nevada Prescribe?

Pharmacists in Nevada can prescribe the following without a prescription:

Vaccinations
Birth control
HIV Pre-Exposure Prophylaxis (PrEP)
HIV Post-Exposure Prophylaxis (PEP)

Conditions and Medications Pharmacists Can Prescribe

Common Conditions and Treatments

The National Alliance of State Protocols (NASPA) has published a map detailing which states allow pharmacists to prescribe and dispense for some of the following medications and conditions:

Vaccinations: Pharmacists can prescribe and administer vaccines in all states, usually under standing orders. Common vaccinations include influenza (flu), COVID-19, shingles, pneumonia, human papillomavirus (HPV), and hepatitis. The RSV vaccine can only be administered with a prescription from the doctor.

Smoking Cessation Medication: In these 17 states, pharmacists can prescribe nicotine replacement therapies and medications like varenicline (Chantix) and bupropion (Zyban) to help patients quit smoking:
- Oregon, Idaho, California, Utah, Arizona, Colorado, New Mexico, Minnesota, Iowa, Missouri, Arkansas, Indiana, West Virginia, North Carolina, Vermont, New Hampshire, and Maine.

Birth Control: Oral contraceptives and hormonal birth control can be prescribed without a CPA in the following jurisdictions, according to NASPA:
- Arizona, Arkansas, California, Colorado, Delaware, District of Columbia, Hawaii, Idaho, Illinois, Maryland, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Oregon, South Carolina, Utah, Vermont, Virginia, and West Virginia.

Naloxone for Opioid Overdose: Pharmacists are able to administer naloxone in all 50 states
Paxlovid for COVID-19: The U.S. Food and Drug Administration (FDA) authorized all licensed pharmacists to administer Paxlovid, an antiretroviral therapy, for the treatment of COVID-19.

Travel Medications for Malaria prevention, traveler’s diarrhea, motion sickness
HIV pre-exposure and post-exposure prophylaxisSome states are expanding their pharmacist prescribing capabilities to test and treat certain conditions such as uncomplicated urinary tract infections (UTI’s), strep, and flu. You can learn more here: Pharmacist Prescribing: "Test and Treat" - NASPA

Benefits of Pharmacist Prescriptive Authority

Because Pharmacists are more accessible to the general public than primary care physicians, there are many benefits to pharmacists having prescriptive authority, such as improved health outcomes, reduced healthcare costs, and convenience for patients.

Improved Health Outcomes

Pharmacist prescriptive authority benefits healthcare as a whole as it increases accessibility to care for all patients and reduces the need for scheduled in-office appointments for minor health issues.

With patients able to receive care within 15-30 minutes of walking into their local pharmacy rather than spending an hour in urgent care or waiting days to weeks to see their doctor, the public can see health improvements faster than ever.

Reduced Healthcare Costs

Increasing accessibility to healthcare also inherently reduces costs. Allowing pharmacists to prescribe medications for common conditions eliminates the high out-of-pocket expenses incurred at an urgent care or hospital visit. Keep in mind, however, that a consultation with a pharmacist may still come with some expense. However, the cost may be significantly lower.

Convenience for Patients

Pharmacists in community pharmacies often work longer hours than in private practices, allowing patients more time and flexibility in their treatment experience.

How Pharmacists Gain Prescriptive Authority

Education and Training Requirements

Pharmacists undergo extensive education to perform these essential duties, including obtaining a Doctor of Pharmacy degree. After graduating from pharmacy school, the pharmacist must pass both the North American Pharmacist Licensure Exam (NAPLEX) and the Multistate Pharmacy Jurisprudence Exam (MPJE) in order to work in a pharmacy. Some states also require pharmacists to go through residency before having prescriptive authority.

Certification and Licensing

Additional training or certifications may be required for pharmacists to assess and prescribe certain medications in certain states. For example, pharmacists in California must obtain an Advanced Practice Pharmacist (APh) license to carry out prescriptive authority. Pharmacists in North Carolina will have to obtain a Clinical Pharmacist Practitioner (CPP) credential to enter into a CPA with a physician. If you are curious about your prescriptive authority as a pharmacist, visit your State Board of Pharmacies website for more details.

Continuing Education and Professional Development

Healthcare is constantly evolving. Therefore, the field of pharmacy is continuously shifting to keep up. Pharmacists are required to complete continuing education (CE’s) courses.

For example, Massachusetts and Florida require additional hours of CE’s to be completed directly related to collaborative practice agreements, and pharmacists in Idaho must complete a CE course on travel medicine in order to independently prescribe these medications.

The Role of Standing Orders and Protocols

What are Standing Orders?

As mentioned previously, standing orders are written guidelines that authorize pharmacists and other qualified healthcare professionals to evaluate a patient's need for medications or vaccines and administer them. Standing orders must be signed by a physician and include the following information:

Which patient population to target for the medical intervention (for example, patients >50 years old for shingles vaccine)
How to assess the patient for the particular vaccine/medication
How to administer the vaccine/medication
Information for the patient, such as a vaccine information statement (VIS) for patients or counseling material
How to document vaccination/medication in patient record
A standard procedure for how to manage medical emergencies related to the intervention
How to report possible adverse events

The Center for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) highly recommends standing orders for certain vaccinations, including influenza, pneumococcal, COVID-19, and others, to increase vaccination rates. Standing orders can be established to allow pharmacists to administer multiple vaccines to a wide range of patients in different healthcare settings, such as community pharmacies, hospitals, clinics, and long-term care facilities. Standing orders have been beneficial in increasing access to care by allowing pharmacists in community pharmacies to host “pop-up” vaccination clinics on college campuses, businesses, and even apartment complexes.

Impact on Prescriptive Authority

Standing orders provide pharmacists with more autonomy and independence. Pharmacists are able to use their clinical judgment when assessing patients and provide care to patients who are likely to fall through the cracks of the healthcare system. With this less restrictive form of prescriptive authority, pharmacists are able to improve health outcomes in more patients.

Case Studies on the Effectiveness of Implementing Standing Orders

The Community Preventive Services Task Force (CPSTF) also recommends standing orders for immunizations after several significant findings from a Community Guide systematic review of 35 studies done in 2009. Twenty-seven (27) out of 35 studies showed a 24% median increase in vaccination rates with the use of standing orders. Nine studies used standing orders alone, which showed an increase by a median of 16%, and 19 studies where standing orders were used in combination with additional interventions showed an increase in vaccination rates by a median of 27%. Standing orders were shown to increase vaccination rates among children by a median of 28% in 4 studies.

The CPSTF confidently concluded from the evidence of the studies that implementing standing orders for vaccines were effective in improving vaccine rates in adults and children, when used alone and in combination with other interventions, and in various settings.

FAQs and Common Concerns

Can U.S. Pharmacists Prescribe Antibiotics?

Depending on the state you live in, your pharmacist may be able to prescribe antibiotics for specific conditions like uncomplicated urinary tract infections. Examples of these states include Idaho, Utah, and Kentucky.

Can My Local Pharmacist Prescribe Medication?

Your local pharmacist may have the ability to prescribe medication for acute conditions based on statewide protocols or collaborative practice agreements. Some states may require pharmacists to have additional training or licensing in order to dispense certain medications for chronic conditions or diseases. The list of medications that pharmacists in your state can prescribe is constantly expanding. Check with your local pharmacist or board of pharmacy to see what medications you may be able to get prescribed from your pharmacist.

What are the Limitations and Responsibilities of Pharmacist Prescribing?

Pharmacists must be licensed and adhere to state-specific laws and regulations regarding prescribing. Many states require pharmacists to work under collaborative agreements with physicians or adhere to state-specific protocols.

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