- Guidelines
- EC Demonstration Project
- Collaborative Protocols in the Demonstration Project
- Pharmacist Training
- Training for Family Planning Staff
- Legislation
- Media
- Public Awareness and Outreach
- California EC Network (2006-2008)
- Pharmacy Participation
- How You Can Get Involved
In California, a law effective January 1, 2002, allows pharmacists to provide Emergency Contraception (EC) to women directly, without them first having to get a prescription from a doctor or clinic. Following the FDA decision to make Plan B EC available without a prescription for consumers 18 and older, all women, including teens and women without proof of age, will still be able to obtain EC directly from specially trained pharmacists (in the states that allow pharmacy access to EC). Click here for more information on the FDA decision.
California, like 40 other states, permits pharmacists to administer drug therapy under collaborative protocols (also known as collaborative practice agreements) with prescribers. However, prior to 2002 when new legislation took effect, California’s collaborative protocols had limited utility in terms of significantly increasing consumer access to prescriptive contraception including emergency contraception. Most pharmacy laws in the United States governing collaborative protocols are intended to be patient specific, and often further specify that the physician first see the patient for the condition being treated by the pharmacist. This provision alone in California prohibited pharmacists operating under collaborative protocols from serving the broader community.
In 2000, Pharmacy Access Partnership undertook a series of steps leading to new legislation in California. Through its Circle of Advisors, it convened a workgroup of physicians, reproductive health specialists, public health experts, and pharmacists to develop and disseminate “California Guidelines for Pharmacies Providing Family Planning Services to the Community”. Using this document as a general reference, it then set out a three-year plan for facilitating new policies in California that would help demedicalize and promote greater consumer access to contraception, with focus on emergency contraception (EC is a method of contraception that can be used soon after unprotected intercourse to prevent pregnancy) in particular.
Pharmacy Access Partnership implemented demonstration projects statewide in California. In these demonstration projects, local providers were persuaded to set up collaborative protocols with pharmacists interested in offering emergency contraception (EC) services. Sites were originally limited to seven counties in California: Los Angeles, Marin, San Diego, San Joaquin, San Francisco, San Luis Obispo, and Santa Cruz. Medical providers included local health departments, university student health centers, managed care plans, Planned Parenthood, and other community clinics. All participating providers served a large volume of family planning clients. Initially, only independent (as opposed to chain) pharmacies committed to participate in the demonstration projects. However, within six months several major chain pharmacies agreed to participate. Pharmacist consultants performed most of the pharmacist recruitment. The Partnership established more than 70 pharmacy demonstration sites statewide that provided EC under protocols, and trained over 100 pharmacists. Small incentive payments were given to participating clinics. Pharmacists were reimbursed $15 an EC encounter for counseling services. Generally, payment for counseling came from Pharmacy Access Partnership, although some clinics assumed this financial responsibility. On most occasions, pharmacists could bill the state government for the commodity. Outreach materials were given to clients at their clinics, informing them that they could also access EC at a participating pharmacy. These demonstration sites helped set the stage for legislation, making California the first state in the nation to pass legislation specifically designed to increase pharmacy access to emergency contraception.
Collaborative Protocols in the Demonstration Project
Under a liberal interpretation of the then-current law, participating pharmacists were permitted to serve (only) clients of the authorizing health care facility. They directly provided clients with emergency contraception and, in most cases, anti-nausea medication. Because participating providers were generally family planning clinics, and their enrolled patients accessed services related to pregnancy prevention, “fertility” was deemed as the condition for which they were being treated, and thus served as the bridge for pharmacist-administered EC.
California Pharmacists Association provided the majority of live EC training programs in the state under contract with Pharmacy Access Partnership. The University of Southern California and Washington State Pharmacy Association also provided accredited EC training programs in California during the start up demonstration phase. Together these groups provided about 55 live trainings in the first year and a half. Group size averaged 28, but varied from 5 to 110 pharmacists.
Training programs were initially 20 hours — 8 hours of home study and 12 hours of live programming. After a year, these programs were shortened to 2 hours of home study and 4 hours of live program. Approximately half of the program was devoted to clinical issues and half to promoting effective communication skills and managing sensitive situations such as minor’s right to confidential service, abuse, etc. Most live trainings in California had two trainers — a pharmacist and a family planning health educator. All trainings stressed the important role pharmacists can play in getting women into care for ongoing contraception, STI/HIV screening etc. A respected family planning training organization, the Center for Health Training helped develop the materials and curriculum for the non-clinical component of the training.
Trainings were offered throughout the state, including rural and remote areas (e.g., Bishop, California) during the first 18 months of implementation. This was a strategic decision to promote statewide participation in California’s widely diverse communities. Costs to participants were kept at a relatively affordable cost of $45 for a four-hour live CE program.
Several pharmacy chains also launched their own programs. The UCSF School of Pharmacy developed a self-study program to serve one chain. This decentralized approach makes it difficult to know the total number of pharmacists trained. However, estimates vary from 2,500-3,000 pharmacists.
As of 2004, a minimum of 1 hour (.1 CEU) of training is required by California law. In June 2004, Pharmacy Access Partnership launched a 1 hour online training program meeting California’s training requirements. In July 2007, the training program was updated and reaccredited.
Training for Family Planning Staff
Half-day training programs were held throughout California for clinicians and other family planning staff during the demonstration phase of California’s EC program. Their purpose was to promote better understanding of EC and encourage family planning staff to consider the important, supportive role pharmacies can play in promoting access to EC. These programs were conducted by the Center for Health Training, which serves many government-funded family planning programs in California and other states.
Work on California state legislation SB1169 was initiated in April 2001, approximately nine months after the demonstration project began. By this time, almost 70 pharmacies were participating in the EC Pharmacy Program. The Public Health Institute, the parent organization of the Pharmacy Access Partnership, sponsored the bill, Senate Bill 1169 (Alpert D-San Diego). Sponsorship was critical to the success of the bill, as the Public Health Institute is an organization dedicated to promoting policies important to the public’s health: it averted perceived “scope of practice” turf issues and minimized debate over abortion. Support from many lawmakers stemmed from their interest in seeing EC as an over-the-counter product. The bill passed both the Assembly and Senate largely along party lines in a legislature controlled by the Democratic Party, and went into effect January 1, 2002.
In 2003, two bills relating to pharmacist provision of EC were passed and went into effect January 1, 2004:
SB490 (Alpert D-San Diego), sponsored by the Public Health Institute, simplifies pharmacist participation in the EC pharmacy program. The bill authorizes the State Pharmacy and Medical Boards to develop a standardized protocol under which trained pharmacists may initiate EC. Like many state-level advancements in deregulating EC, California’s proposed policy change is modeled after another state – New Mexico. Trained pharmacists are now able to download the protocol from www.pharmacy.ca.gov and provide services. The system will require no formal notification or enrollment process by pharmacists. The bill requires pharmacists to have a minimum of 1 hour of CE training and does not specify provider type or training format. SB 490 had the support of organized medicine, women’s groups and the pharmacy community.
SB545 (Speier D-San Francisco/San Mateo), sponsored by the American College of Obstetricians and Gynecologists, sets a $10 price cap on the amount pharmacists may charge for the assessment and counseling component of the service. This “administrative” fee is independent of charges for the drug or the traditional dispensing fee. To address the equity issue, the bill also prohibits physicians from charging patients more than $10 for EC (non-drug costs) that is prescribed as a result of contact made by telephone or electronic means. SB 545 had the strong support of organized medicine and women’s groups, but was opposed by pharmacy groups.
SB 644 (Ortiz D-Sacramento), sponsored by Planned Parenthood Affiliates of California, requires CA pharmacies to fill all legal prescriptions for medications that are in stock and if not available, requires the pharmacy to refer to another local pharmacy. Effective January 1, 2006, SB 644 mirrors the California Pharmacist Association’s Code of Ethics and states that CPhA “supports the right of any pharmacist to object on ethical, moral or religious ground….The pharmacist must provide prior notification… so that a system may be developed to ensure that patients have access to legally prescribed therapy and/or pharmaceutical care.” Pharmacy Access Partnership joined many national colleagues on the late-breaker resolution (PDF-44K) sponsored by the American Public Health Association 2005 Annual Meeting and conference, to promote such a referral policy.
Medi-Cal covers no more than 1 pack of Plan B per month per client, with no more than 6 packs in a 12-month period.
The vast majority of broadcast and print media coverage has been favorable. The EC pharmacy demonstration projects generated considerable interest, with the three major newspapers in California (the Los Angeles Times, San Francisco Chronicle and Sacramento Bee) carrying front page stories. Interestingly, very few reporters made the distinction between “over-the-counter” and “behind-the-counter” when reporting on the demonstration projects or SB1169, perhaps playing to what they knew would be a good story.
Because of the high costs for paid media in California’s major markets, Pharmacy Access Partnership has relied on alternative strategies to promote awareness about pharmacy access to EC. One key strategy has been the development and distribution of printed materials for consumers through mass mailings. This central strategy supplemented other efforts including presentations at regional and statewide conferences, seminars and public events and a very limited amount of paid media.
To increase public awareness and help women find pharmacies that provide EC, Pharmacy Access Partnership developed a website (www.ec-help.org) and hotline (discontinued hotline Dec. 2006). In the first two years of full implementation they received about 60,000 visitors and calls. The website and hotline were extremely important in the initial phase when some women knew about the law change permitting pharmacy access, but were uncertain which pharmacies were providing service.
Ogilvy Public Relations Worldwide designed and produced a line of consumer informational and promotional materials that promoted pharmacy access to EC, and featured the EC-Help hotline and website. Materials were field tested for readability and design approval and include panel cards, wallet cards, brochures, flyers and posters for pharmacies.
Pharmacy Access Partnership developed a mailing list of approximately 2,000 community-based organizations (CBOs) including Title X and other family planning clinics, primary care clinics, Maternal and Child Health and WIC Directors, local health departments and other community-based organizations. With the help of CBOs, these materials were publicly distributed. The CBO database was compiled to ensure that all counties, including urban, rural and remote locations, were represented. Initially mass mailings of consumer materials were shipped to organizations on a county-by-county basis to coincide with start up of local EC pharmacies. Additionally consumer materials have been provided free of charge to each pharmacy that has signed up on the EC-Help hotline and website.
There has been a limited amount of paid media in Spanish, Korean, Vietnamese and alternative press newspapers. This advertising provided an avenue for diverse communities to learn about pharmacy access to EC. In Spring 2003, the Partnership ran a radio ad (DOC-24K) on two popular stations in the Los Angeles and San Francisco Bay areas.
EC pharmacies are located in 52 of the 58 counties in California and can be found in about 60% of California’s rural counties. Click here for a map (DOC-84K) of CA counties with EC pharmacies. Non-participating counties are rural or remote and have few, if any, pharmacies. Pharmacies have informally developed networks in many communities in which they refer women seeking EC to the designated local EC pharmacy.
There is a lot you can do to promote consumer access to emergency contraception in pharmacies. We encourage pharmacists, physicians, clinics and student health centers, community organizations, and the media to get involved in this important public health effort. Your participation is essential to build this new system of care and strengthen efforts to reduce unintended pregnancy.
There are a number of ways to get involved:
- Pharmacists – Become an EC provider and offer services in your pharmacy. To find out more, please visit Becoming an EC Provider and view an informational brochure for pharmacists on the EC Pharmacy Program.
- Clinics and Physicians – Support EC services in your community by partnering with a local pharmacy. Establishing protocols with one or more community pharmacies is an excellent way to promote referrals to your practice. Remember, many clients served by the pharmacist will not have an established relationship with a provider. Inform your clients about EC availability in pharmacies. To find out more, please visit our sections on EC Collaborative Protocols and EC Promotional Materials and view an informational brochure for physicians on the EC Pharmacy Program.
- Community Organizations, Student Health Services, WIC Centers, and Social Service Agencies – Help promote public awareness about how to access EC in pharmacies. Your efforts are critical in letting the community know about this new and easy way to obtain EC. To find out more, click here.
- General – Learn more about the important role pharmacies can play in promoting community health.