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Table 1.  Availability of Hormonal Contraception Prescribed by a Pharmacist in California Pharmaciesa
Availability of Hormonal Contraception Prescribed by a Pharmacist in California Pharmaciesa
Table 2.  Characteristics of Pharmacist-Prescribed Hormonal Contraception in California Pharmacies
Characteristics of Pharmacist-Prescribed Hormonal Contraception in California Pharmacies
1.
National Alliance of State Pharmacy Associations.  Pharmacists authorized to prescribe birth control in more states. https://naspa.us/2017/05/pharmacists-authorized-prescribe-birth-control-states/. Accessed August 19, 2017.
2.
California State Board of Pharmacy.  Self-Administered Hormonal Contraception Protocol for Pharmacists. Sacramento, CA: California State Board of Pharmacy; 2016.
3.
California Legislative Information.  Senate bill no. 493. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB493. Accessed November 7, 2017.
4.
Gonsalves  L, Hindin  MJ.  Pharmacy provision of sexual and reproductive health commodities to young people.  Contraception. 2017;95(4):339-363.PubMedGoogle ScholarCrossref
5.
Rodriguez  MI, McConnell  KJ, Swartz  J, Edelman  AB.  Pharmacist prescription of hormonal contraception in Oregon.  J Am Pharm Assoc (2003). 2016;56(5):521-526.PubMedGoogle ScholarCrossref
6.
California Legislative Information.  Assembly bill no. 1114. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB1114. Accessed November 7, 2017.
Research Letter
December 12, 2017

Availability of Pharmacist-Prescribed Contraception in California, 2017

Author Affiliations
  • 1Sexual Health and Reproductive Equity Program, School of Social Welfare, University of California, Berkeley
JAMA. 2017;318(22):2253-2254. doi:10.1001/jama.2017.15674

California is 1 of 4 states currently permitting—but not requiring—pharmacists to prescribe contraception.1 Since April 2016, patients can obtain hormonal contraceptive pills, injections, rings, and patches in California pharmacies offering this service.2 After patients complete a health questionnaire (and, for combined hormonal contraception, a blood pressure reading), trained pharmacists determine medical eligibility for methods, conduct counseling, and prescribe contraception.2 Although insurers are not required to reimburse pharmacies for this clinical service, pharmacies may charge patients fees.3

To date, the extent to which pharmacies are making pharmacist-prescribed contraception available under these nascent policies has not been estimated; this study does so at 1 year after implementation began in California.

Methods

The Office for Protection of Human Subjects at the University of California, Berkeley, deemed this study to be nonhuman subjects research. A telephone audit study of a representative sample of California pharmacies was conducted between February 2017 and April 2017. A list of all licensed pharmacies (n = 7048) was obtained from the California State Board of Pharmacy in October 2016. Hospital, clinic, university, and specialty and other non–full-service pharmacies (eg, long-term care, mail order) were identified and excluded. A random sample of 20% of included pharmacies was used—stratified by urbanity (census tract designation) and pharmacy type (retail chain or independent, defined as <5 locations). With a power level of 0.85 and an α of .05, the minimum sample size required to detect an effect size of 0.1 in χ2 tests of independence comparing availability of pharmacist-prescribed contraception by urbanity or pharmacy type was 898.

To assess availability of pharmacist-prescribed contraception, trained interviewers used a structured data collection instrument. Posing as patients, interviewers called pharmacies and said: “I heard that you can get birth control from a pharmacy without a prescription from your doctor. Can I do that at your pharmacy?” If pharmacy staff responded affirmatively, interviewers inquired about service fees and method availability, documenting contraceptive methods spontaneously mentioned.

Proportions with 95% CIs, medians with interquartile ranges (IQRs), and χ2 tests comparing differences in availability by urbanity and pharmacy type were estimated using Stata (StataCorp), version 13.1. Statistical significance was set at 2-tailed P value of less than .05.

Results

The sampling frame included 5291 community-based, retail pharmacies. A random sample of 1058 pharmacies was drawn, with data collected from 1008 (95.2%). Most pharmacies were urban (85.7%) and affiliated with chains (70.3%) (Table 1). Pharmacist-prescribed contraception was available in 11.1% (95% CI, 9.3%-13.2%) of pharmacies, with no significant availability differences by urbanity or pharmacy type. Among pharmacies offering this service (n = 112), 67.9% (95% CI, 58.5%-75.9%) indicated a specific fee requirement (median, $45 [IQR, $40-$45]) (Table 2). Most chain pharmacies (86.3% [95% CI, 76.2%-92.6%]) had set fees compared with independent pharmacies (33.3% [95% CI, 20.2%-49.7%]) (P < .001). When queried about method availability, contraceptive pills were referenced most frequently (77.7%), followed by rings (40.2%), patches (38.4%), and injections (8.9%).

Discussion

One year after California pharmacists were permitted to prescribe contraception, a minority of pharmacies offered this service. Previous research highlights barriers to implementation, including concerns about training, liability, and staffing.4,5 Most pharmacies offering pharmacist-prescribed contraception required a fee for this service, particularly retail chains. Even when contraception is available in pharmacies, it may not be economically accessible because of fees. In California, lack of insurance reimbursement may undergird low availability of pharmacist-prescribed contraception. Additional legislation (effective in July 2017) requires California's Medicaid program to reimburse for pharmacist services by July 20216; the implementation timeline and lack of private insurance coverage may still present barriers to increasing availability of this service.

The strengths of this study include use of a large, representative sample of pharmacies and the high response rate. Limitations are assessment of service availability via phone and inclusion of only 1 state. Additionally, availability of each method was not systematically ascertained.

Pharmacist-prescribed contraception could facilitate contraceptive use for many women. With at least 9 states implementing or considering allowing pharmacist-prescribed contraception,1 continued research is needed to identify barriers to accessibility of this clinical service.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Corresponding Author: Anu Manchikanti Gomez, PhD, MSc, Sexual Health and Reproductive Equity Program, School of Social Welfare, University of California, Berkeley, 110 Haviland Hall MC 7400, Berkeley, CA 94720-7400 (anugomez@berkeley.edu).

Accepted for Publication: September 15, 2017.

Author Contributions: Dr Gomez had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gomez.

Acquisition, analysis, or interpretation of data: Gomez.

Drafting of the manuscript: Gomez.

Critical revision of the manuscript for important intellectual content: Gomez.

Statistical analysis: Gomez.

Supervision: Gomez.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Gomez reports participating in a scientific advisory board meeting and receiving grant funding from Gilead Sciences unrelated to this study.

Additional Contributions: Thanks to Colleen McCullough, BA (University of California, Berkeley [UCB]), for serving as project coordinator, a role for which she was compensated; and to Colleen Hoff, PhD (San Francisco State University [SFSU]), for her role in developing the study; Rafaela Fadda, MSW, Brittany Ganguly, MSW, Elena Gustafson, MSW, Nicolette Severson, MSW, and Jake Tomlitz, MSW (all from UCB), for their assistance in designing the study and training interviewers; and Tracy Brooks, Ilhaam Burny, Rachel Crowley, Alicia Cuevas, Amacalli Duran-Pereda, Josie Lee, Alejandra Leon, Lorraine Meriner Pereira, Louise Stephan, BA, and Patricia Torres (all from UCB), and Rachel L. Henry, MA (SFSU), for their work as interviewers; and Jennet Arcara, MPH, MPP, and Stephanie Arteaga, MPH (both from UCB), for providing feedback on this article. They did not receive compensation for their contribution.

References
1.
National Alliance of State Pharmacy Associations.  Pharmacists authorized to prescribe birth control in more states. https://naspa.us/2017/05/pharmacists-authorized-prescribe-birth-control-states/. Accessed August 19, 2017.
2.
California State Board of Pharmacy.  Self-Administered Hormonal Contraception Protocol for Pharmacists. Sacramento, CA: California State Board of Pharmacy; 2016.
3.
California Legislative Information.  Senate bill no. 493. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB493. Accessed November 7, 2017.
4.
Gonsalves  L, Hindin  MJ.  Pharmacy provision of sexual and reproductive health commodities to young people.  Contraception. 2017;95(4):339-363.PubMedGoogle ScholarCrossref
5.
Rodriguez  MI, McConnell  KJ, Swartz  J, Edelman  AB.  Pharmacist prescription of hormonal contraception in Oregon.  J Am Pharm Assoc (2003). 2016;56(5):521-526.PubMedGoogle ScholarCrossref
6.
California Legislative Information.  Assembly bill no. 1114. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB1114. Accessed November 7, 2017.
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