Tag: pharmacist prescribing

Measuring Blood Pressure: An Important Prerequisite to Prescribing Hormonal Contraception

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Why is it important to measure blood pressure before prescribing hormonal contraception?

Combined hormonal contraceptives (CHCs) are a relatively safe and effective method for your patients in preventing pregnancy and treating other disease states such as menorrhagia, endometriosis, PCOS and more. However, CHCs may increase the risk for a few serious cardiovascular events. This risk is increased if a patient has hypertension.

Screening for hypertension prior to staring CHCs is a class A recommendation for safe use according to the U.S. Selected Practice Recommendations for Contraceptive Use (SRC). In a systemic review, women who did not have their blood pressure checked prior to starting hormonal contraception had higher odds of having an acute myocardial infarction and ischemic stroke.

Also, in a small percentage of patients, CHCs can cause life-threatening hypertension, which can lead to irreversible damage to the kidneys and cause renal failure. This effect can last after the medication is discontinued.

Due to these severe adverse effects, all patients are screened for hypertension prior to starting CHCs. If a patient is hypertensive, they should be treated appropriately and have blood pressure well controlled prior to starting a hormonal contraceptive method.  

How do CHCs raise blood pressure?

The mechanism by which CHCs increase blood pressure is unknown. Regardless, CHCs can cause small increases in blood pressure in both normotensive patients and patients with hypertension which is significant enough to be recognized as a risk for hypertensive patients.

Who is at risk of complications from CHCs?

It is not advised to use CHCs in patients with severe hypertension (defined as systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 100 mmHg). However, in people with controlled and monitored hypertension and who are also under 35 years of age, CHCs may be appropriate as long as they are otherwise healthy and do not smoke (U.S. MEC 3). It is important to mention that even if a patient has hypertension that is under control, there is still a risk present for cardiovascular events and that other contraceptive options should be considered before initiating a CHC.

Patients are at a higher risk of cardiovascular complications if they are older than 35 years of age, have a familial history of hypertension, cardiovascular disease or preexisting occult renal disease, and if the patient is obese. Providers should use discretion in patients with these preexisting conditions before starting CHCs or consider more appropriate contraceptive options.

What other options are there for patients with hypertension?

Patients with uncontrolled hypertension, or who are at risk of malignant hypertension have other options for contraception. Progestin only contraceptives such as progestin only pills (POPS), the shot, or levonorgestrel-containing IUDs are recommended over CHCs according to the CDC MEC for women with hypertension. Non-hormonal options include the copper-containing IUD, condoms, or spermicides.

References

  1. Tepper NK, Curtis KM, Steenland MW, Marchbanks PA. Blood pressure measurement prior to initiating hormonal contraception: a systematic review. Contraception 2013;87:631–8.
  2. CDC. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep (No. RR-X);2016.
  3. Development, updates, and future directions of the World Health Organization Selected Practice Recommendations for Contraceptive Use. Int J Gynecol Obstet 2017;136: 113–119 – 04 January 2017
  4. Armstrong, Carrie. Hormonal Contraceptives in Women with Coexisting Medical Conditions. Am Fam Physician. 2007 Apr 15;75(8):1252-1258.
  5. El-Ibiary SY, Shrader SP, Ragucci KR. Contraception. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill; Accessed July 22, 2020. https://accesspharmacy-mhmedical-com.mwu.idm.oclc.org/content.aspx?bookid=2577&sectionid=227710658

About the Author

Elizabeth Duxbury Pharm.D. is a recent graduate of University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences in 2019.

Article reviewed by Breanna Failla, PharmD Candidate and Brooke Griffin, PharmD, BCACP

Contraception During COVID-19: Pharmacy Best Practices

Pharmacists should not allow postponed or cancelled appointments to keep patients from accessing birth control. It’s important that patients understand how their pharmacy can continue to meet their contraceptive needs during the coronavirus disease 2019 (COVID-19) pandemic.

Pharmacists should inform patients that even though clinics and providers’ offices might be closed, their pharmacy is still able to facilitate refills, provide emergency contraception, and, in some states, prescribe hormonal contraception.

The following tips can help ensure your pharmacy is meeting patients’ contraceptive needs during COVID-19, while keeping your patients and pharmacy staff safe.

1. Encourage Contactless Communications and Dispensing 

Prevent patients from missing doses or going without contraception by preemptively contacting them via texts, emails, and calls to assess their needs. Encourage patients to utilize contactless communication to get in touch with the pharmacy for prescriptions or other items they want to order.

Pharmacies can provide contactless contraceptive care during COVID-19 by encouraging patients to obtain birth control prescriptions and products via mail, drive-through, or curbside pick-up services.1 


2. Promote and Supply Over-the-Counter Products

Visits to the pharmacy may be very limited for patients because of stay-at-home orders, social distancing, and other COVID-19-related barriers. Preemptively supplying prescriptions for emergency contraception can avert out of pocket costs while mitigating stress for patients that experience method failure and are unable to access the pharmacy in a timely manner.2 Encourage patients to have a pregnancy test on hand, in addition to over-the-counter contraceptive options, to ensure that patients’ contraceptive needs are met when routine visits to the pharmacy are not feasible.


3. Optimize Prescriptions and Anticipate Patient Needs

To maintain social distancing and the health of patients and employees, encourage providers to transmit new prescriptions electronically or via telephone.1 

Prescriptions for birth control should include maximum quantities and refills for a full year’s supply.2 Some states require health plans to cover dispensing a 12-month supply of birth control.3 Dispense the maximum amount allowed by the patient’s insurance and share the cash price if a patient desires paying out-of-pocket to limit visits to the pharmacy or clinic.

Pharmacy staff can proactively review patients’ profiles to anticipate upcoming refills and ensure the pharmacy’s birth control inventory is adequate to fulfill patient needs.2 

Check with your state’s COVID-19 pharmacy executive orders to ensure permitted emergency refills are being authorized.


4. Adapt Pharmacist Prescribing

Utilize Telehealth for Birth Control Visits

Patients are turning to telehealth services to access contraception during COVID-19. Transitioning your contraception service to telehealth wherever possible will ensure continuity of care while protecting the health and safety of patients and employees. Pharmacists can utilize telehealth to initiate contraception, assess and switch current methods, and adjust therapy as needed.

Due to COVID-19, some telehealth HIPAA regulations have loosened and health insurance plans are beginning to cover telehealth services.4 

Offer Methods that Don’t Require Blood Pressure Screening

Encourage patients to consider a progestin-only contraceptive if they’re unable to visit the pharmacy for a blood pressure screening.

Progestin-only contraceptive methods do not require a blood pressure screening in order to be safely prescribed, making them a feasible option when prescribing birth control via telehealth. Progestin-only options that can be prescribed by pharmacists and dispensed at the pharmacy include progestin-only pills (containing norethindrone or drospirenone) and depot medroxyprogesterone acetate injections (subcutaneous or intramuscular formulations).

Blood pressure measurement is required prior to initiating combined hormonal contraceptives—containing both estrogen and progestin hormones—due to the increased risk of stroke and myocardial infarction in patients with hypertension or without blood pressure measurements.

This article was co-written by Whitney Russell, a student pharmacist at University of Kentucky College of Pharmacy, and Kailey Hifumi, a student pharmacist at the Pacific University School of Pharmacy.

This article was originally published in Pharmacy Times.

Click image to view and download our COVID guide.

Find out more about providing contraceptive care during COVID-19 on our COVID resource page

References

  1. CDC. Guidance for pharmacies during COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pharmacies.html; Published April 14, 2020. Accessed May 15, 2020.
  2. Family Planning National Training Center. What family planning providers can do to meet client needs during COVID-19. https://www.fpntc.org/resources/what-family-planning-providers-can-do-meet-client-needs-during-covid-19. Accessed May 15, 2020.
  3. Kaiser Family Foundation. Oral contraceptive pills. Available at: https://www.kff.org/womens-health-policy/fact-sheet/oral-contraceptive-pills/. Published May 23, 2019. Accessed May 15, 2020.
  4. Beyond the Pill. Contraceptive care during COVID-19. https://beyondthepill.ucsf.edu/contraceptive-care-during-covid-19. Accessed May 15, 2020.

5 Pearls from the States Forum on Pharmacist Birth Control Services

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States Forum on Pharmacist Birth Control Services

The inaugural States Forum on Pharmacist Birth Control Services was recently held in conjunction with the American Pharmacists Association (APhA) 2019 Annual Meeting in Seattle, Washington. This session was hosted by Birth Control Pharmacist. Most states were represented at the forum with over 60 participants, and there was meaningful discussion on how to make this service not only possible, but also impactful.

Sally Rafie, PharmD kicked off the program with a review of the current landscape. Sharon Landau MPH followed by facilitating brief updates from the states, including those that have implemented pharmacist birth control services, are in progress, and are considering this action. State representatives shared successes, challenges, and lessons learned. Don Downing, BSPharm then led a focused discussion on payment for pharmacist services.

Here are 5 pearls to take away from the States Forum:

1. Even states that tend to be conservative, particularly with women’s health, should consider pursuing policy. 
Legislation to allow pharmacist birth control services is a nonpartisan effort. While some of the early states had Democratic lawmakers sponsoring bills, more than half of those passed and under consideration are sponsored by Republican lawmakers.

2. Avoid certification because this is standard practice for pharmacists. 
Payment for pharmacist services is critical to success. Multiple states cited this as the biggest challenge they are currently facing. Health plans may look for “certification” to credential a pharmacist as a provider or pharmacists assessing a body system to determine the service is eligible for payment. Washington has had success with payment for pharmacist services by recognizing pharmacists as medical providers and using legislation to mandate payment for pharmacist services by all government and private health plans.

3. Provide education for pharmacists and identify pharmacist and physician champions in advance of proposed legislation.
Pharmacists are not the only stakeholders who champion initiatives for pharmacist birth control services in the states; legislation has even moved forward without necessarily engaging the state pharmacist associations or other pharmacists. In some states, pharmacists have more concerns than other stakeholders and may even testify in opposition of proposed legislation. Many of these concerns may be due to knowledge gaps and can be addressed with education opportunities in advance of legislation. Identifying physician champions is important, particularly for testifying in support of any proposed legislation. Check with local teaching hospitals for family planning fellows who will likely be enthusiastic about engaging in this work.

4. We need to promote our birth control services as a profession, as well as individual pharmacists and pharmacies that offer the service.
While pharmacists are getting trained and geared up to provide this service, the public remains largely unaware. Some pharmacies are seeing low patient demand for their birth control services. With over 1100 participating pharmacies on the birthcontrolpharmacies.com map, there is an opportunity to have a greater impact in serving communities.

5. Join us next year for the States Forum. 
Pharmacists valued sharing ideas, experiences, best practices, and strategies. Especially those in states who are considering legislation found the forum to be helpful. States that were farther along in implementing pharmacist birth control services were more than willing to share and help other states.

This article was originally published in Pharmacy Times.

Payment for Pharmacist Services in California

As of April 2019, California’s State Medicaid program, Medi-Cal, is providing payment for selected pharmacist services. This change is due to legislation (California Assembly Bill 1114) that was passed in 2016.

Medi-Cal Medicaid Payment Reimbursement Pharmacist Services

What is covered?

Pharmacist services are benefits for eligible fee-for-service Medi-Cal beneficiaries.

The following pharmacist services are now covered:

  1. Hormonal contraception
  2. Immunizations
  3. Tobacco cessation
  4. Travel health
  5. Naloxone

At this time, Medi-Cal is allowing pharmacists to bill for the following CPT codes:

  1. 99201 – New Patient (~10 minutes)
  2. 99212 – Established Patient (~10 minutes)
  3. 90471 – Immunization administration only

A new patient is one who has not received any pharmacist services at the same pharmacy in the last 3 years. An established patient has received pharmacist services at the same pharmacy within the last 3 years.

The rate of reimbursement for pharmacist services is 85% the physician rate. This is a change for reimbursement of the pharmacist service only. There is no change to the reimbursement for any medications that are furnished (prescribed and dispensed) — those have always been reimbursed at the same rate regardless of what provider type wrote the prescription. 

Pharmacist services must be billed by a Medi-Cal enrolled pharmacy. Since payment will be made to the pharmacy (and not any individual pharmacists), bills must be submitted by the pharmacy and include the rendering provider/pharmacist information.

How do pharmacists get started with billing?

Pharmacists must enroll as an Ordering, Referring, and Prescribing Provider (ORP Provider) with the California Department of Health Care Services (DHCS) in order to bill for these services. 

Before beginning the enrollment process, pharmacists will need:

  • A Type 1-Individual National Provider Identification (NPI) number. It is free to sign up for your NPI number online and only takes a few minutes.
  • A digital copy of their pharmacist (RPH) pocket license from the California Board of Pharmacy.
  • A digital copy of their California Drivers License.

To complete the ORP Provider enrollment process, follow these steps:

  1. Go to the PAVE Portal. If you are a pharmacy owner, you likely already have an account that you use to manage your pharmacy’s Business Profile account. You can invite your staff pharmacists as users for the pharmacy’s Business Profile, so that they may associate themselves with the pharmacy. 
  2. Select New Application.  
  3. Select “I’m new to Medi-Cal and I want to create a new application” and “I’m an individual licensed/certified healthcare practitioner. See screenshot below. PAVE 1
  4. For Business Structure, select “I’m an Ordering/Referring/Prescribing (ORP) provider.” See screenshot below. pave-2.png
  5. For NPI number, enter your Type 1-Individual NPI number. This is your personal pharmacist NPI number, not the pharmacy’s NPI number. See screenshot below.pave-3-e1561883852442.png
  6. For Provider type, select Other and type “Pharmacist” in the box. See screenshot below.pave-4.png
  7. For the remaining steps, follow the instructions to complete your application.  TIP: When entering your professional license information, there should be no space between the alpha character and the license number. For example, enter your pharmacist license as RPH12345 without any spaces.

For technical support, call the PAVE Help Desk at (866)252-1949, Monday – Friday, 8:00 am – 6:00 pm Pacific time, excluding state holidays.

When can I start billing?

Visit dates on April 1, 2019 or after can be billed to Medi-Cal. Pharmacists will need to wait for their enrollment as an ORP provider to be approved before they can begin billing — you should expect this to take 3 months and may take up to 6 months.

How do I bill?

All claims must be submitted using CMS Form 1500.

For more information about billing procedures and documentation requirements, see the Medi-Cal Bulletin and follow the link under Item 1 to the provider manual.

 

References

How to Set Your Birth Control Formulary and Inventory Levels

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Inventory management can either make or break a pharmacy or clinic. It’s one of those things that you absolutely must keep a close eye on. Otherwise, things can go from good to bad and bad to worse very quickly.

For the patient, their most basic expectation is to walk into the pharmacy with their shiny, new prescription and leave with their medications in hand. That’s why it is absolutely crucial to carefully set your birth control formulary and appropriately set your inventory levels.

Birth Control Pharmacist Formulary Inventory

Which birth control products should I keep in stock? 

If you are in a pharmacy that is already dispensing birth control prescriptions, you likely don’t need to make many changes at all! You can pick from the existing products that other birth control users are happy with when prescribing for your patients.

If you starting up and are a low volume clinic or pharmacy, simplicity is the key. Don’t stock your shelf full of 5 different equivalent generics that can be substituted for one another. Pick the one generic that is most cost effective or one that your patients most often request.

Choose medications to have on hand that can’t be substituted. Always keep Nuvaring, Xulane, and Depo-Provera or its generic on hand. These formulations are great options for people who have trouble adhering to a daily regimen or just don’t want to think about taking a pill every day.

Be sure to stock progestin only pills, extended cycle combination oral contraceptive (COC) pill packs, as well as emergency contraception because…well it’s in the name that it’s an emergency (Ella and Plan B One Step or generic). POPs are important to have stocked for your patients who may have contraindications to estrogen, such as migraines with aura or may be in the immediate postpartum period. There is only one progestin only pill formulation – norethindrone 0.35 mg.

When selecting the COCs to keep on hand, try to utilize the progestin’s class effects to your patient’s advantage. There are about 40 COC formulations on the market today. Narrow down the abundance of options when choosing your formulary by looking at how the progestins differ from one another. For instance, stock a COC that contains a progestin with low or no androgenic activity such as norgestimate or drospirenone respectively if your patient is concerned about or struggling with acne.

Other noncontraceptive benefits of hormonal pills that patients may request will be to suppress their menses. This is why we always want to have an extended regimen or even better a continuous regimen COC pack readily available. Yes, some of these are costly items that may not be your store’s “fast movers”, but having different formulations and the chance to get started on these right away will pay off in the end. The result being happy patients, happy pharmacy staff, and a larger base of pharmacy patrons.

Speaking of cost, inventory — if managed incorrectly — can come back to haunt you. Carefully controlling the inventory is how you will manage the potentially devastating high-cost of some medications. Like before, consider birth control options that cannot be substituted and limit your inventory on products that seem to have endless substitutions. Also, if you’ve noticed some insurances prefer certain products over others, keep that in mind as well.

How do I determine how much to keep on hand?

Once you’ve established what products you would like to keep on hand, look at your pharmacy’s dispensing history for each product. How many times do you dispense that product in a month’s time? Do you have a patron that comes in like clockwork every month for Yaz or LoLoestrin? Someone returning every three months for her 3-month supply? Here’s where utilizing a patient compliance tool to schedule refills, with the patient’s permission, can be extremely

Take all of these factors into account and utilize your inventory system’s options to set an order point or TIL (target inventory level). This will tell your computer to automatically order that medication once your BOH (balance on hand) drops below your pre-determined TIL. Most pharmacy systems have some version of this function and it can be a really helpful tool. The point here is to make sure you don’t have thousands of dollars in inventory sitting on your shelf gathering dust and worst case scenario expiring on the shelf. On the other side of that coin, you don’t want to turn patients away because you don’t stock the product that they are consistently picking up on a monthly It’s important to find a balance.

Patients in California and selected other states can now request up to an annual supply of their birth control to be dispensed and state law requires their health insurance company to cover this. Want to know more? Check out our recent article with more details.

Hopefully you find these tips useful in setting your birth control formulary and inventory.

About the Author:

Candace Stifflemire is a fourth-year pharmacy student at the University of the Incarnate Word Feik School of Pharmacy in San Antonio, Texas.

Colorado is Third State Allowing Pharmacists to Prescribe Birth Control

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More good news about access to birth control is coming from the state level. Colorado has passed legislation authorizing pharmacists to prescribe birth control after obtaining additional training. They are the third state to follow California and Oregon with this statewide authority specific to birth control. There is a task force that is charged with implementing the new protocol in the coming months.

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Pharmacist Protocols

All state protocols to date require pharmacist training and patient screening with a questionnaire and blood pressure measurement. Colorado’s legislation most closely resembles Oregon’s in allowing initiation of birth control pills and patch to adult women for up to three years until she sees a physician. California’s protocol is more comprehensive in allowing initiation of birth control ring and injection as well, in addition to serving female patients of all ages without a duration limit.

Public Health Impact

In 2010, 45% of all pregnancies (43,000) in Colorado were unintended. This expanded pharmacist scope is great news for women in Colorado and affords them more choices in access points for birth control. Colorado pharmacists are also looking forward to providing this important public health service to their patients.

It is yet to be determined what types of patients utilize this service when offered by pharmacists. The service became available at participating pharmacies as of January 2016 in Oregon and April 2016 in California.

Colorado has had great success with other initiatives to address unintended pregnancies. The Colorado Department of Public Health and Environment Family Planning Initiative provided more than 30,000 intrauterine devices (IUDs) or implants at low or no cost to low-income women. This contributed to a 40% drop in the teen birth rate from 2009 through 2013. This project is among others in demonstrating that when cost and access barriers to long-acting, reversible contraceptive methods such as IUDs and implants are removed, women are likely to choose these more effective methods. By 2019, Colorado aims to reduce the unintended pregnancy rate to 30% or less as one of their “Winnable Battles.”

Safety

There have been concerns about the safety of providing hormonal contraception without physical exams and pap smears. Though hormonal contraceptives are not without risks, these are generally outweighed by the benefits and considered safe for most women. A pelvic examination and a pap smear are not necessary to initiate hormonal birth control.  They are important for other health reasons.  Women will need to complete a health history questionnaire and have their blood pressure taken at the pharmacy.  The pharmacist will use this information to determine which methods of birth control are safe.

This is another step forward in increasing access to birth control.  Hopefully more states will pass similar laws expanding access with pharmacist prescribing.

There is also growing support for over-the-counter birth control pills. That differs from pharmacist prescribing because consultation with a pharmacist would no longer be required.

This article was originally published in Pharmacy Times.

MPR Ask the Experts Interview

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A few months ago, I was interviewed by the team at Monthly Prescribing Reference (MPR) regarding pharmacist prescribing of oral contraceptives. The newsletter has just been published and I want to share with you all as it is a great reference if you are interested in prescribing oral contraceptives.

In the 16-page newsletter dedicated to this topic, you will see both my responses as well as responses from Dr. Lorinda Anderson of Oregon to the following questions:

In your opinion, what are the implications of legislation allowing qualified pharmacists in California and Oregon to prescribe and dispense certain types of contraceptives? What is your take on how women perceive these new laws?

Under the Affordable Care Act, insurance plans are permitted to use cost sharing to encourage or discourage use of specific contraceptive products. In your opinion, how much does cost sharing influence the decision of which OC to prescribe? Are there any concerns that cost sharing could prevent a patient from receiving the OC that is optimal for her?

When choosing from among the many combination OCs available, how do the doses of estrogen factor into your decision (if at all) regarding which OC to prescribe?

For which patients and under what circumstances might one opt to prescribe a progestin-only OC or a combination OC?

What questions/concerns should pharmacists expect to address when counseling a patient who is being prescribed an OC?

In your experience, what are some common side effects that may occur with OC use? In the event that a patient finds specific side effects persistent and/or bothersome, what do you recommend in terms of next steps?

In what type of situation should a pharmacist refer patients to a women’s healthcare professional or other healthcare provider for contraception?

What would you like to communicate to your colleagues regarding the appropriate training and knowledge that should be acquired in order to begin prescribing contraceptives? Can you recommend any relevant resources that your colleagues could consult if needed?

Do you have any concluding remarks that you would like to share with our readers?

Please see the full newsletter here.

Thank you to MPR and Teva Generics for supporting this important content for pharmacists.