Become an early adopter in allowing pharmacists to provide pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP), advocates say, because it’s taking years to revise the California law to ensure maximum coverage. Although several other states have surpassed California, the state legislature is proposing a so-called “cleanup law” that will ensure pharmacists face fewer hurdles—such as payment—in providing the meds.
Only one in four people in the U.S. who could benefit from PrEP is taking the medication, which is a key reason the National HIV/AIDS Strategy for the United States called for PrEP and PEP to be prescribed and provided by pharmacists. The idea is, asking for these meds in a less stigmatizing setting like a pharmacy would expand access in communities that need it most and could cut out some steps and travel. By allowing pharmacists to prescribe and provide PrEP and PEP, a patient would, in theory, no longer need to get HIV test results from a lab, take them to a doctor to get a prescription, then head to the pharmacy for the meds—several times a year, assuming the pharmacy also offers HIV testing—not a sure thing. Research has shown that LGBTQ+ people in the U.S., especially Black, Latinx and younger people—the groups who could most benefit from PrEP—are less likely to access healthcare. Sexual health clinics often provide one-stop shopping for PrEP, but these facilities are more often in urban areas. In other areas, pharmacists are the most accessible healthcare providers.
According to the American Pharmacists Association, as of last fall, 17 states had expanded pharmacists’ authority to provide PrEP or PEP at community pharmacies or clinics. But not all of those states provide reimbursement to the pharmacies for the extra staffing and testing services, which has limited the benefits of these expansions.
California was the first state to authorize pharmacies to provide PrEP and PEP, through Senate Bill 159, but since the law went into effect in 2020, lawmakers have since been trying to plug holes in the law. Shortly after SB 159 was passed, I reported for the Center for Health Journalism that pharmacists were unlikely to opt-in to provide PrEP because the law didn’t authorize payment for on-site HIV testing or any of the training or staffing needed to provide the meds. The likeliest scenario was, if a pharmacist did choose to provide the meds, customers would have to get their labs at a testing center if there was one in the community, then come back for PrEP or PEP, an extra step that could make some think twice. A negative HIV test is required to obtain PrEP/PEP, and the Affordable Care Act mandates that HIV testing must be free for those with insurance. But it’s not always easy to find a place offering HIV tests, especially in pharmacies, which don’t necessarily get paid by insurers for the service.
A recent study conducted by the California HIV/AIDS Policy Research Centers and the Center on Reproductive Health, Law and Policy at UCLA concluded that SB 159 did not expand availability of PrEP in the way lawmakers hoped. In this survey of 900 California pharmacists and pharmacy students an overwhelming majority said they never furnished PrEP or PEP services and less than two-thirds had heard of SB 159.
Last year the California legislature introduced Senate Bill 339, which was signed into law in January, to address some of these issues. The law extends the supply of PrEP and PEP meds that pharmacists may supply from 60 days to 90 days, and requires health plans to pay for the meds, as well as the pharmacist’s time and testing services. But according to some California pharmacists, SB 339 still falls short of ensuring equitable access to HIV testing and PrEP/PEP.
In a survey of 900 California pharmacists and pharmacy students an overwhelming majority said they never furnished PrEP or PEP services and less than two-thirds had heard of SB 159.
“Pharmacists must be reimbursed in order for the chain and independent pharmacies to devote resources to their staff to provide the services [and] they can’t do it unless there is a path to payment,” wrote Maria Lopez, president of Mission Wellness Pharmacy in San Francisco. One problem with the latest law, she said, is that California doesn’t enforce payment for new workflows, education, testing or the meds.
Picking up after the cleanup law
In late April, the California legislature heard testimony from Lopez and others supporting yet another bill to revise the current law and eliminate regulatory hurdles preventing more pharmacists from offering the prevention meds. If passed, the new bill, SB 966, would put some enforcement behind the previous law’s mandate to pay pharmacies, according to advocates.
SB 966 would create new Pharmacy Benefit Manager (PBM) regulations and curb what advocates call abusive billing practices. In introducing the bill in January, state senator Scott Wiener said, “We cannot allow these middlemen to continue charging exorbitant and unfair prices while Californians are forced to ration life-saving medication.”
“The previous law said that health plans were not required to cover PrEP or PEP prescribed ‘by a pharmacist at an out-of-network pharmacy, unless the health care service plan has an out-of-network pharmacy benefit,’ which has been an obstacle to providing PrEP and PEP,” said Dr. Clint Hopkins, owner and pharmacist at Pucci’s Pharmacy in Sacramento, in an email. Hopkins testified before the legislature in favor of the previous two laws.
“We continue to run into barriers with some health plans citing that we are ‘not in network’ and not wanting to contract with us. All we can do is turn them in to the Department of Insurance and see if they will be able to force them to allow us in,” Hopkins added.
As written, SB 966 would allow patients to get PrEP and PEP through any pharmacies, in-network or not, and prohibit “spread pricing” where PBMs charge a plan more for a drug than it pays pharmacies. It also would require the PBM to pass along drug rebates to plans or directly to patients and prohibit direct or indirect fees to the patient.
Beyond the issue of paying for PrEP and PEP, pharmacists have not been reimbursed for their time or on-site testing, if they offer it. SB 339 set no requirement that the commercial or Medicare plans pay a reasonable rate for services. For Medicaid, a compromise to get the previous legislation passed was insertion of “85% of the fee schedule for physician services” found in SB 339,” according to Hopkins. “We don’t get a 15% discount on purchasing HIV testing or labor costs involved in providing services,” he said. “Our costs are the same as a physician’s costs and we should be paid the same.”
Every state regulates its pharmacists and insurers differently. Lopez said regulation of the insurance industry has been “historically weak” in California, leaving pharmacists on the hook not only for PrEP and PEP services, but for COVID work, such as testing, even when mandated to reimburse by the Emergency Federal Directive, which ended in 2023.
Other issues hampering the distribution of PrEP and PEP include stipulations that the California Board of Pharmacy makes on what a pharmacist is allowed to do, Lopez said, which sometimes override federal guidelines, such as mandating a 60-day supply of PrEP when the CDC required a 90-day supply. Mandated state education and training on PrEP and PEP protocols, which don’t align with education requirements of the CDC, also present barriers to care that Lopez and Hopkins hope the new law will eliminate.
LARRY BUHL is a multimedia journalist based in Los Angeles. He has covered HIV/AIDS and other infectious diseases for more than two decades. In addition to POSITIVELY AWARE, he is a regular contributor to TheBody.com, Everyday Health and capitalandmain.com. His work has appeared in USA Today, Salon, Undark, KQED, The New York Times and others.