Pharmacies can control what prescriptions they fulfill and which medications they stock, in some cases basing their decisions on moral reasoning. Amid the current diabetes medication shortage and with abortion access dwindling, pharmacies play a pivotal role in health care, wielding control over the lives of millions of patients. But state laws and economic pressures often dictate pharmacists' use of discretion when filling prescriptions.
What power do pharmacies have?
Many pharmacies, especially large companies like CVS and Walgreens, have significant control over the medications they stock and dispense. Pharmacists also have the final say when it comes to fulfilling prescriptions, allowing them to simply refuse to fill them. Pharmacies are legally allowed to deny fulfilling prescriptions at the discretion of the pharmacist.
Diabetes medication is one of the areas that pharmacies have leveraged control over. Medications including Ozempic and Mounjaro are in low supply largely because they have been adopted as weight-loss solutions. This has left both Type 2 diabetes patients and pharmacies in a tough spot. In turn, pharmacies have taken to prioritizing diabetes patients over those using the drug exclusively for weight-loss purposes despite being given prescriptions, per Healthline.
"High demand at the pharmacies means increased demand for manufacturers," Nancy Mitchell, a registered nurse and writer for the Assisted Living Center told Healthline. Limiting access to those drugs is "a means of dialing down on the urgency to manufacture more of the drug, dispensing it to those who are, for now, on the top of their priority list legally," she said. However, patients who use the drug for obesity are dealing with the consequences. "Obesity can lead to diabetes. Diabetes can lead to obesity," remarked Dr. Beverly Tchang, an endocrinologist and assistant professor at Weill Cornell Medicine, to Healthline.
Some pharmacies have opted to not carry Ozempic because the shortage is making it expensive to carry and insurance payouts are not covering the cost. "Many pharmacies will look at medicines that are being significantly underpaid and make a business decision to not let that drug deep-six their entire business," Antonio Ciaccia, the CEO of nonprofit 46brooklyn that researches drug pricing, told NBC News.
Also, following the overturning of Roe v. Wade (1973), many pharmacies were given the power to deny prescriptions for medication that could be used for abortions, even if it wasn't being used for that purpose, USA Today reported. For example, a person can be denied misoprostol, which can be used for abortions but also to prevent stomach ulcers. Some states also allowed for prescriptions to be denied due to moral disagreement, like in the case of birth control.
Why are pharmacies allowed to deny prescriptions?
Like the government, the health care system operates on a system of checks and balances. Since pharmacists are medical experts in their own right, they can exercise discretion on drug dispensing. "Just as doctors have the ability to decide whether or not to prescribe a medication, pharmacists are given professional discretion to fill or not fill prescriptions," according to Verify.
"Pharmacists are not machines. They always use judgment in dispensing," Donald Miller, a professor of pharmacy practice at North Dakota State University, told Verify. "Most of the time what is right is dispensing the prescription as written, but many times the right thing is to not fill it or more commonly clarify it." This is especially the case if a prescription is incorrect or if the drugs could clash with the medications the patient is currently taking. Pharmacists essentially act as a second round of defense after doctors.
This is all the more helpful as "polypharmacy," the simultaneous use of multiple medicines by a patient for their conditions, is becoming more common, per The Economist. "Of Americans who are 65 or older, two-thirds take at least five medications each day." According to the Lown Institute, medication overload "will lead to the premature death of more than 150,000 older Americans" in the next decade. The side effects of taking numerous meds have caused incorrect diagnoses and, in some cases, overdose deaths. Opioid painkillers and mental health medications have been the medications most overprescribed.
Pharmacists essentially double-check if "it's the right patient, the right drug, the right dose, the right route — how they're taking that medication — and then the right time," said Anna Legreid Dopp, a senior director at the American Society of Health-System Pharmacists, to Verify.
Where there's more controversy is in states that allow pharmacies to deny prescriptions for moral reasons. Six states allow pharmacists to refuse to dispense birth control medication and Plan B because of moral disagreement without having to recommend the prescription to another pharmacy. Some company policies may require prescriptions to be transferred. For example, Walgreens said in June 2020 that it "allows pharmacists to step away from filling a prescription for which they have a moral objection" but added that "they are also required to refer the prescription to another pharmacist or manager on duty to meet the patient's needs in a timely manner."
Because of this, the Biden administration released guidance stating that pharmacists refusing to fill prescriptions for abortion and birth control drugs may violate federal law, specifically those preventing pregnancy and disability discrimination, Reuters reported. "We are committed to ensuring that everyone can access health care, free of discrimination," said Department of Health and Human Services Secretary Xavier Becerra. "This includes access to prescription medications for reproductive health and other types of care."
Are pharmacies and pharmacists too powerful?
Pharmaceutical expertise is important in protecting patients' health. "The more pills someone takes, the more likely it becomes that some of them will interact in harmful ways," stated The Economist. "Pharmacists have reference databases that they check for nasty drug interactions." Catching prescription errors can potentially save lives. However, "druggists shouldn't act as morality police," according to the editors of Scientific American. "These professionals are hurting people, especially women, when they force them to go hunting for a place to fill a prescription."
There are state laws that inhibit pharmacists from doing their jobs. While some deny prescriptions for moral reasons, many located in states with anti-abortion laws fear the legal ramifications of fulfilling prescriptions for abortion drugs. "In some cases, we see risk in the pharmacist being disciplined or facing legal liability if they do something at the state level but then also facing legal liability from the federal level if they don't," explained Dopp. "That's a really hard place to practice, and that's not in the best interests of patients."
"As long as there is a reasonable expectation that the prescription is legitimate, you should be fine. I think pharmacies refusing to fill this is mostly fear and confusion and overreaction," remarked Miller. "I understand the fear … but I think if you're using your professional judgment appropriately for the benefit of that patient, that's a really ironclad defense."