Health Care Services Provided by North Carolina Pharmacists

Background

A National Academies of Science, Engineering, and Medicine (NASEM) report summarized strategies to rebuild the foundation of primary care.¹ High-quality primary care was defined as continuous, person-centered, relationship-based care that includes input from patients, families, and communities, and recommendations included: "1) Pay for primary care teams to care for people, not doctors to deliver services; 2) Ensure that high-quality primary care is available to every individual and family in every community; 3) Train primary care teams where people live and work; 4) Design information technology that serves the patient, family, and the interprofessional care team; 5) Ensure that high-quality primary care is implemented in the United States.¹

To achieve these goals, pharmacists must be comprehensively incorporated into health care teams. With this in mind, NASEM convened a two-day workshop in 2025 to examine the impact of pharmacists on health-care systems, and proceedings of this meeting will be published in the future.²

North Carolina legislators have recognized the important contributions of pharmacists to patient access and quality of care and passed innovative legislation in 2021 and 2025 to capitalize on their skills in medication optimization. This paper will discuss how pharmacists provide essential health care services and will highlight ground-breaking legislation expanding pharmacists’ authorization to practice under collaborative practice agreements and statewide protocols.

Session Law 2025-37: Collaborative Practice Agreements Between Physicians and Clinical Pharmacist Practitioners

Over 25 years ago, North Carolina was one of the first states to recognize advanced practice pharmacists who provide drug therapy management under collaborative practice agreements (CPAs) with physicians.³ Clinical Pharmacist Practitioners (CPPs) are licensed by the North Carolina Board of Pharmacy and the North Carolina Medical Board to initiate, modify, and discontinue medications in collaboration with their attending physician in the context of interprofessional teams.³ CPPs provide comprehensive medication management for patients with chronic conditions in primary care, specialty clinics, and health systems⁴; optimize medications during Medicare wellness visits⁵; and promote safe transitions of care.⁶ At the Mountain Area Health Education Center, CPPs provide health care services for specialized populations, including those with a substance use disorder, osteoporosis, and hepatitis C.^3,7 According to the North Carolina Board of Pharmacy, there are currently 459 CPPs in our state, which is an increase from 87 in 2011.⁴

Despite the long-standing history of this advanced practice model, modernized legislation has been needed to address barriers to widespread implementation across North Carolina. For example, original legislation did not allow physician assistants (PAs) and nurse practitioners (NPs) to participate in pharmacists’ collaborative practice agreements and did not address credentialing and payment by insurers. Consequently, CPPs serve in a consultant role for physician assistants and nurse practitioners and are only compensated as providers by North Carolina Medicaid, creating practice inefficiencies and limiting financial sustainability.

To address these obstacles, the North Carolina legislature passed House Bill (HB) 67 into law as Session Law 2025-37 in July 2025 to update the role of the CPP, enhance interprofessional care, and increase access to pharmacists’ care.⁸ Services provided are now termed “health care services” instead of “drug therapy management,” and CPPs are authorized to substitute and order medications, tests, and devices that assist with drug therapy, disease, or population health management, as outlined in a written agreement with the physician and pharmacist.⁸ Components of health care services are further described in Table 1.

Supervising physicians can now add PAs and NPs to their collaborative practice agreements to elevate interprofessional collaboration. Pharmacists can be fully or partially embedded into a site-specific practice, and location is outlined in the CPA.⁸ Additionally, credentialing and payment by insurers was addressed in the updated legislation and is discussed later in this article. These transformations to CPP legislation are expected to increase the number of pharmacists who practice as advanced practice pharmacists and increase the quality of care provided for patients.

Test and Treat

Session Law 2025-37 also authorized pharmacists to order and perform a Clinical Laboratory Improvement Amendments (CLIA)-waived test and initiate treatment for influenza under statewide protocol. The North Carolina Board of Pharmacy, the North Carolina Medical Board, and the State Health Director will work collaboratively to ensure patient safety and access to care provided by pharmacists and will establish guidelines for referrals for additional care.⁸ A qualitative assessment of “test and treat” services in pharmacies in Washington State noted a reduction in workload burden for rural physicians,⁹ which could be beneficial for health systems during the upcoming influenza season.

House Bill 96 / State Law 2021-110: From Standing Orders to Statewide Protocols

Pharmacists in North Carolina have served as immunizing pharmacists for over 20 years and administered over 278 million COVID-19 vaccines during the pandemic.¹⁰ Because of this significant impact on public health outcomes, new opportunities for pharmacists to further increase access to care were evaluated. House Bill 96 (HB 96) was a bipartisan bill that was passed into law as Session Law 2021-110; the bill extended the role of the pharmacist in community settings to better meet public health needs by authorizing pharmacists to initiate certain medications to improve outcomes in maternal health, smoking, diabetes, and HIV prevention (Table 2).¹¹

After the bill passed into law, leaders from the North Carolina Association of Pharmacists (NCAP), North Carolina Board of Pharmacy, and the North Carolina Department of Health and Human Services (NCDHHS) worked collaboratively to create standing orders (and later statewide protocols) to authorize pharmacists to initiate medications such as hormonal contraception, nicotine replacement therapy, and glucagon. Additional provisions in Session Law 2021-110 included the ability to administer long-acting injectable (LAI) medications after appropriate training.¹¹

Hormonal Contraception (HC)

A survey of North Carolina pharmacists reported that 83% of those practicing in community settings were likely to prescribe hormonal contraception (HC) if legislation was passed, training was provided, and other barriers such as time constraints and liability were addressed.¹² Respondents reported that access to HC is an important public health issue and would particularly benefit patients in rural communities.¹² In response to these findings, NCAP appointed a task force to evaluate legislation, scope of practice, payment for services, and training in other states. Findings from the task force informed the development of proposed legislation, pharmacist training, statewide protocols, workflow, and documentation.

Immunizing pharmacists who complete a 5-hour, self-paced online training developed by NCAP are eligible to initiate combined estrogen/progestin pills and patches and progestin-only pills. Training includes a review of contraceptive methods, case discussions, North Carolina requirements for patient assessment and documentation, and principles of reproductive justice. During encounters, patients complete a form adapted from the Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria for Contraceptive Use (MEC) and have their blood pressure measured to determine if they are a candidate for contraceptive methods within the pharmacists’ scope.¹³

A Contraception Summit was held in Chapel Hill in August 2023 to bring together over 80 leaders from pharmacy, medicine, NCAP, the North Carolina Board of Pharmacy, North Carolina Medicaid, NCDHHS, advocacy groups, legislators, payers, and the reproductive justice community.¹⁴ The goal of the conference was to share experiences from early adopters of pharmacist-initiated HC, learn from thought leaders from other states, and explore strategies for implementation. Attendees identified that payment for clinical services and a public awareness campaign were necessary to ensure success. In response to these recommendations, North Carolina Medicaid created a payment model¹⁵ and Points True North Consulting developed a marketing plan that included logos, scripts for “on-hold” calls in the pharmacy, and social media advertisements.¹⁶ The birth control pharmacy logo can be found in Figure 1, and birth control pharmacists are encouraged to incorporate it into their marketing in the pharmacy and on websites and social media to increase patient awareness of this service.

Figure 1.Logo for Pharmacist-Initiated Hormonal Contraception

Source: Eshelman School of Pharmacy, University of North Carolina at Chapel Hill.

Pharmacists counsel patients about all contraceptive methods, consider patient preferences in clinical decision making, and refer patients to primary care to receive additional reproductive health services or a contraceptive that is not within their scope, such as an implant, vaginal ring, injection, or intrauterine device.¹³ According to NCAP, 1880 pharmacists have completed the training, and data from the University of North Carolina Eshelman School of Pharmacy demonstrated that 93% of North Carolina counties have a birth control pharmacy.

Pharmacist Administration of Long-Acting Injectable (LAI) Medications

Immunizing pharmacists in North Carolina with additional training are authorized to administer long-acting injectable (LAI) medications to patients aged 18 years and older, pursuant to a prescription.¹¹ An LAI is defined as a “drug product formulated to produce sustained release and gradual absorption of the active pharmaceutical ingredient over an extended period of time after administration by subcutaneous or intramuscular injection”.¹⁷ While the statute explicitly includes testosterone and vitamin B12 injections, examples of other long-acting injectables include, but are not limited to, haloperidol decanoate, fluphenazine decanoate, paliperidone palmitate, and naltrexone.¹¹

According to a North Carolina Board of Pharmacy (NCBOP) rule, immunizing pharmacists who wish to exercise expanded authority for LAI administration are required to complete and document training for subcutaneous and intramuscular injections. NCAP offers a 5-hour LAI training.

Pharmacist administration of long-acting injectables leverages pharmacist expertise in medication therapy, skills in medication administration, and proximity to patients. There are numerous benefits to a collaborative care model in which pharmacists administer long-acting injectables to patients. Pharmacy locations have extended service hours in the evenings and on weekends; patients already visit the pharmacy for other prescriptions; medications are typically on hand for same-day administration; patients may arrange an appointment at the pharmacy to facilitate shorter wait times; and waste is minimized, as the long-acting injectable is not billed until after administration occurs. Additionally, the pharmacist counsels the patient before medication administration and reports administration details to the patient’s prescriber. Pharmacist-administered LAI can be particularly impactful for patients who live in rural communities or are unable to access care at physician practices during regular working hours, creating new interprofessional partnerships for community pharmacists and physicians.

North Carolina Pharmacy Finder

Pharmacies that are participating in the provision of enhanced pharmacy services are encouraged to register in a statewide, searchable, online database developed by NCAP that allows both patients and health care professionals to locate a needed service at www.ncpharmacyfinder.com.¹⁸ A review of this database in March 2025 indicated that 18% of pharmacies were providing contraceptive services, making it the most utilized statewide protocol. This database underestimates the number of pharmacies providing health care services, and NCAP is seeking to increase awareness and uptake. Patients and providers who are unable to locate a pharmacy via this website are encouraged to contact pharmacies in their area to determine where a particular service can be accessed.

Payment for Services Provided by Pharmacists

Historically, insurers have compensated pharmacies only for medications dispensed. Over time, payment models in community pharmacy settings have not kept pace with the cost of medications, negatively impacting financial sustainability and leading to pharmacy closures and deserts. Advocacy efforts at the state and national level seek to reform pharmacy benefit manager (PBM) practices to ensure that patients have access to affordable medications.¹⁹

Community pharmacists who provide birth control services can be credentialed by North Carolina Medicaid under taxonomy 2 as providers, and CPT codes have been established to support claim submission (NCDHHS).²⁰ This allows pharmacies to submit claims and receive payment for the clinical service in addition to the dispensed contraceptives. Medicaid now pays for the over-the-counter progestin-only pill.

CPPs can be credentialed with North Carolina Medicaid under taxonomy 3 to bill independently in physician practices¹⁵; however, Medicare and other third-party payers have not uniformly recognized pharmacists as providers, which limits billing to a CPT 99211 level and decreases the likelihood that primary care practices can afford to include a pharmacist on their interprofessional team.

Session Law 2025-37 addressed challenges associated with fragmented payment models and included pioneering language to guide health benefit plans. The law states that insurers in North Carolina shall cover health care services provided by a pharmacist if all the following conditions are met: “1) The service or procedure was performed within the pharmacist’s licensed lawful scope of practice; and 2) The health benefit plan would have covered the service if the service or procedure had been performed by another health care provider”.⁸ This advancement in payment reform is anticipated to increase the scale and impact of pharmacists who are practicing under statewide protocols and collaborative practice agreements.

There remains a need for Medicare to recognize pharmacists as providers under the Social Security Act or establish payment models for health care services provided by pharmacists to address the complex medication needs of the growing population of older adults. The Future of Pharmacy Care Coalition consists of over 170 organizations representing pharmacists, patients, and rural communities who support federal legislation to provide Medicare coverage for essential pharmacist services.²⁰

Conclusion

This year (2025) has been an exciting year for the pharmacy profession in North Carolina. Legislative wins have authorized pharmacists to provide a greater number of essential health care services, benefiting patients, team-based care, communities, and health systems. Pharmacists are driving innovation in medication optimization and are integral members of interprofessional teams who positively impact patient care outcomes.

Acknowledgments

The authors would like to thank Catherine Read, and Jill Sergison with Points True North Consulting for their leadership for the pharmacist-initiated hormonal contraception initiative.

Declaration of interests

Drs. Scott, Savage, and Marciniak report that they have received funding from The Duke Endowment.