Prescribing Authority for Pharmacists: Rules and Regulations by State
Key takeaways:
Pharmacists in the U.S. are now allowed to prescribe nirmatrelvir/ritonavir (Paxlovid), which is used for the treatment of COVID-19, to eligible patients.
Many states, however, have allowed pharmacists to prescribe certain medications and adjust dosages for some time, including for minor ailments and chronic conditions.
Laws about pharmacist eligibility and licensing, as well as scope of practice, vary widely, with some states even allowing pharmacists to prescribe controlled substances.
Pharmacists are a valuable and integral part of the healthcare system. One study found that patients see their pharmacists more often than any other healthcare provider, perhaps because pharmacists tend to be more accessible or because patients need to pick up their medications every 30 or 90 days.
Pharmacists are healthcare providers. They are trained to be the drug experts. But their role has gradually evolved to include more direct patient care activities. However, their ability to prescribe is still limited.
Pharmacists prescribing authority across the U.S.
Although requirements vary by state, some states give pharmacists the ability to prescribe medications, modify drug therapy, give vaccines, and conduct lab tests. Some have standing orders, while others, like North Carolina, require an advanced practice license.
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Paxlovid
On July 6, 2022, the FDA authorized all state-licensed pharmacists to prescribe Paxlovid, an antiviral used for the treatment of COVID-19.
Pharmacists are required to confirm that Paxlovid is being prescribed for eligible patients. Eligible patients must:
Be 12 years of age and older and weigh at least 40 kg (about 88 pounds)
Have mild to moderate COVID-19 and have positive COVID-19 test results
Be at a high risk of developing severe COVID-19 that leads to hospitalization or death
In addition, pharmacists prescribing Paxlovid must make sure the following conditions are met:
Sufficient information is available to assess hepatic and renal function. Sufficient information includes electronic medical records less than 12 months old or a conversation with the patient’s healthcare provider.
The patient’s comprehensive medication list is available, so the pharmacist can assess potential drug interactions. This can also come from their medical records, from their healthcare provider, or through a conversation with the patient.
The pharmacist must refer the patient to a physician, nurse practitioner, or physician associate when any of the following apply:
Sufficient information is not available to assess hepatic or renal function, or to assess potential drug interactions.
One of the patient’s medications must be adjusted due to its interaction with Paxlovid.
Paxlovid is not appropriate for the patient, either based on the information contained in the fact sheet or due to drug interactions where monitoring would not be feasible.
Limited prescribing
In addition to Paxlovid, a growing number of states and jurisdictions are allowing pharmacists to prescribe a limited formulary of medications like birth control, naloxone, tobacco cessation products, preventative HIV medications, and travel-related medications. These areas include:
50 states that allow pharmacists to prescribe naloxone
20 jurisdictions that allow pharmacists to prescribe birth control
17 states that allow pharmacists to prescribe smoking cessation products
Several states that allow pharmacists to dispense pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for HIV prevention without a doctor’s prescription
Expanded prescribing
In some states, pharmacists have been given even more authority to prescribe additional medications, like those to treat minor acute conditions. These states include:
New Mexico
Oregon
Idaho
Florida
California
North Carolina
Montana
New York
Iowa
Massachusetts
Ohio
New Mexico, California, Montana, and North Carolina require an additional credential on your license. This means that to become an independent-prescribing pharmacist, you’ll need to apply for and acquire an advanced license.
States with expanded prescribing authority
Next, we’ll review what you need to know about licensure, requirements, and regulations in the seven states that authorize pharmacists to prescribe.
New Mexico
New Mexico was the first state to allow pharmacists to prescribe. It passed legislation in 1993 to stave off a predicted primary care provider shortage, which persists to this day.
Pharmacists who obtain the Pharmacist Clinician Certification can provide primary and specialty care, which allows them to prescribe medications (including controlled substances) for chronic and non-chronic conditions.
Prescribing criteria
After earning your pharmacy licensure in New Mexico, you can apply to become a Pharmacist Clinician. But you must first complete a course on physical assessments and also complete an experiential portion overseen by either a physician or other practitioner with prescribing authority.
Even without a Pharmacist Clinician license, pharmacists in New Mexico are allowed to prescribe birth control, emergency contraception, tobacco cessation medicine, and naloxone. This is in addition to giving vaccines to people of any age and also providing tuberculin testing services.
Oregon
In Oregon, pharmacists can prescribe drugs that are on a state-authorized formulary or Protocol Compendia. This formulary includes a list of drugs, devices, and supplies. Of note, pharmacists cannot prescribe to themselves or immediate family members.
The formulary includes devices and supplies for:
Diabetic blood sugar testing supplies
Injection supplies
Nebulizers, spacers, and peak flow meters
International Normalized Ratio (INR) testing
Enteral nutrition supplies
Ostomy products
The Protocol Compendium allows pharmacists to write 60-day supply prescriptions for patients continuing therapy, up to two times a year for any non-controlled medication. It also allows pharmacists to prescribe for:
Cough and cold symptoms, like pseudoephedrine and benzonatate
Vulvovaginal candidiasis (VVC)
Preventative care, like emergency contraception and condoms
Tobacco cessation and nicotine replacement therapy
Travel medicine, like travel vaccines, malaria prophylaxis, antibiotics for traveler’s diarrhea, and acetazolamide for altitude sickness
HIV post-exposure prophylaxis (PEP)
Prescribing criteria
In order to independently prescribe in Oregon, pharmacists:
Must be located and licensed in Oregon
May only dispense from the formulary set forth by the state
May only perform a patient assessment — including diagnosing and collecting subjective and objective information — in an in-person interaction
Must give the patient’s primary care provider notice of the prescription within 5 business days of prescribing it
Must maintain all prescribing records for at least 10 years
Idaho
In 2018, House Bill 191 (HB 191) was passed, allowing pharmacists to independently prescribe more than 20 categories of medications. This means that pharmacists are now able to decide if patients are candidates for independent prescribing or if patients should be referred to a healthcare provider.
Prescribing criteria
In order to independently prescribe in Idaho, pharmacists:
Must maintain good standing for an active license issued by the Idaho Board of Pharmacy
Must notify the patient’s primary care physician within business 5 days of prescribing
Pharmacists in Idaho may only prescribe the following categories of medications:
Florida
House Bill 389 (HB 389) expands pharmacy practice to include certain drug therapy services with collaborative pharmacy practice agreements (CPPA), and testing and treatment for certain minor, non-chronic health conditions under a written protocol with a supervising physician.
Pursuant to a CPPA, pharmacists can initiate, modify, or discontinue drug therapy for the following conditions:
Arthritis
Asthma
Chronic obstructive pulmonary diseases
Type 2 diabetes
HIV or AIDS
Obesity
Any other chronic condition adopted in rule by the Florida Board of Pharmacy (the Board), in consultation with the Board of Medicine and Board of Osteopathic Medicine
Prescribing criteria
To enter into a CPPA in Florida and prescribe medications, a pharmacist must, at a minimum:
Hold an active license in good standing
Have earned a PharmD or obtained at least 5 years of experience as a licensed pharmacist
Complete an initial 20-hour course approved by the Florida Board of Pharmacy, in consultation with the state Board of Medicine and the state Board of Osteopathic Medicine, that includes training in performance of patient assessments, ordering, performing, and interpreting clinical and laboratory tests related to collaborative pharmacy practice and managing diseases
Renew their license every 2 years with an 8-hour continuing education course related to collaborative practice agreements
Maintain professional liability insurance coverage
Establish a system to maintain patient records for at least 5 years from the most recent date of service
Establish a CPPA that is appropriate to the pharmacist’s training and services being provided
In addition to the above, Section 465.1895 adds that pharmacists with a written protocol with a Florida licensure supervising physician can test, screen for, and treat the following minor, acute health conditions:
Influenza
Streptococcus
Lice
Skin condition like ringworm and athlete’s foot
Uncomplicated, minor infections
Similar to the prescribing criteria for entering a CPPA, the written protocol must meet certain terms and conditions, be appropriate for the pharmacist’s training, and be approved by the board. The list of terms and conditions can be found here. One thing to note is that a pharmacist must obtain written approval from the owner of the pharmacy as an employee.
California
For California, Senate Bill 493 was passed in 2013 by Governor Jerry Brown. The bill recognizes pharmacists as healthcare providers who have the authority to deliver several healthcare services. This bill also introduced the Advanced Practice Pharmacist (APh) license.
Advanced Practice Pharmacists can:
Initiate, adjust, and discontinue drug therapy
Order and interpret drug-related tests
Evaluate and manage diseases in collaboration with other healthcare providers
Refer patients to other healthcare providers
Prescribing criteria
Pharmacists looking to pursue an APh and prescribe medications will need to go through the California Board of Pharmacy, have an active pharmacist license in good standing, and meet two of the three following requirements:
Obtain or earn a certificate that aligns with your area of practice (e.g., Board of Specialty Pharmacy certification)
Have completed a postgraduate residency in the U.S. through an American Society of Health-System Pharmacists (ASHP)-accredited program
Have completed 1,500 hours of clinical experience — which includes initiating, adjusting, modifying, or discontinuing drug therapy — under a collaborative practice agreement or protocol to patients within 10 years of the APh application
Any experience used to satisfy one of the three criteria above cannot also be used to satisfy another one of the three criteria.
North Carolina
A Clinical Pharmacist Practitioner (CPP) is a licensed pharmacist who has prescribing authority, including the ability to prescribe controlled substances under the supervision of a licensed physician. In order to become a CPP, the pharmacist must also obtain a new license that is only approved by the North Carolina Board of Pharmacy. You can apply here.
Prescribing criteria
To obtain a CPP and prescribe in North Carolina, the state Board of Pharmacy requires pharmacists to have an active and unrestricted license in the state of North Carolina. They must also meet one of these three criteria:
1) Completed or earned one of the following qualifications:
Certification from the Board of Pharmaceutical Specialities
Completion of an ASHP-accredited residency program that includes 2 years of clinical experience approved by the board
2) Obtained a Doctorate of Pharmacy degree, completed 3 years of clinical experience that are approved by the board, and completed a certificate program from either the North Carolina Center for Pharmaceutical Care (NCCPC) or the American Council on Pharmaceutical Education (ACPE)
3) Obtained a Bachelor of Science in Pharmacy, completed 5 years of clinical experience approved by the board, and completed two NCCP- or ACPE-approved certificate programs
Montana
Montana is another state that has expanded prescribing authority for pharmacists. Like North Carolina, Montana now also offers a Clinical Pharmacist Practitioner certification for this purpose.
Prescribing criteria
In order to obtain the CPP certification and prescribe in Montana, pharmacists must:
Have an active, unrestricted license to practice pharmacy in the state of Montana
Hold a Board of Pharmacy Specialties (BPS) certification from Montana or a nationally recognized equivalent that is approved by the Montana Board of Pharmacy
Provide a signed collaborative practice agreement with a description of the supervision taking place
In addition to these criteria, pharmacists may have to appear before the state board either virtually or in person.
New York
In New York, pharmacists may participate in collaborative drug therapy management (CDTM). The participating pharmacist must be employed or affiliated with an eligible facility that is under article 28 of the public health law, which includes diagnostic and treatment centers or hospital-based outpatient departments — including outpatient clinics — in order to apply.
Prescribing criteria
Pharmacists need at least 2 years of experience, with a minimum of 1 year of clinical experience involving consultation with physicians in terms of drug therapy if you have a PharmD or MS in clinical pharmacy. For pharmacists with a BS, a minimum of 3 years experience within the last 7 years is required.
All clinical experience must be completed within 3 years after submission of the application.
Pharmacists must also complete either an accredited residency program or board certification status from an accredited body.
Massachusetts
Massachusetts-licensed pharmacists also may participate in collaborative drug therapy management (CDTM). They are eligible to participate in a wide variety of settings, including retail pharmacies, ambulatory care clinics, hospitals, and long-term care facilities, subject to specific requirements for each facility type.
Prescribing criteria
Maintain professional liability insurance.
Have 5 years of experience as a licensed pharmacist, earned a Doctor of Pharmacy degree, or completed other education or residency criteria the board deems equivalent to 5 years of experience.
Devote a portion of the practice to the drug therapy area the pharmacist is going to help manage.
Complete an additional 5 hours of continuing education every year in the practice area of the collaborative practice agreement.
Iowa
Collaborative drug therapy management in Iowa is when an authorized provider allows an authorized pharmacist to provide the service through a community practice protocol or when a pharmacy and therapeutics committee gives approval to an authorized pharmacist through a hospital practice protocol.
Prescribing criteria
Hold an active license and be in good standing.
Meet one or more of the following:
Completed a Doctor of Pharmacy (PharmD)
Complete an American Society of Health-System Pharmacists (ASHP)-accredited residency program
Have approval from the Board of Pharmacy
Obtain a Board of Pharmacy Specialties (BPS) certification
Complete the National Institute for Standards in Pharmacist Credentialing disease state management exam and credential
Have a written protocol, either community or hospital practice
Ohio
In Ohio, pharmacists may enter a consult agreement with physicians.
Once pharmacists have entered into a consult agreement, they become managing pharmacists who can:
Issue a prescription for medications specified in the consult agreement
Act as an agent of the provider, in the case of non-controlled dangerous drugs
Summary table of expanded prescribing authority by state
The bottom line
Pharmacists across the U.S. are now able to prescribe and dispense Paxlovid for certain patients who are at high risk of severe disease from COVID-19. Pharmacists in several other states are also able to prescribe a limited formulary of medications, which is one step toward making access to healthcare simpler.
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