In the weeks since the Supreme Court issued its ruling in Dobbs v. Jackson Women’s Health Organization, which allows states to make abortion illegal, there has been a raft of stories about patients with chronic illnesses being denied their prescriptions for methotrexate, a common autoimmune medication seen as the “gold standard” treatment for arthritis, lupus, Crohn’s, and other conditions. Uncertainty around what can legally be dispensed given the new abortion restrictions, especially in states with so-called “trigger laws,” has put doctors, pharmacists, and patients in the crosshairs of potential legal repercussions.
This is not about rogue individual pharmacists acting unilaterally, though. It turns out that the largest pharmacy chain in the country sent explicit instructions to its pharmacists informing them that new checks would be implemented to confirm the reason a doctor prescribes a drug before filling routine medications for patients.
Rebecca, a pharmacist at a CVS in Alabama, who did not want her real name used, said that CVS headquarters sent a memo to pharmacies in “high-risk” states after the decision came down. The memo, which she shared with me, and which has not previously been reported, explicitly states that as a result of Dobbs, Alabama, Arkansas, Idaho, Montana, Oklahoma, and Texas “have implemented laws creating potential criminal liability for any individual who knowingly or recklessly dispenses an ‘abortion-inducing drug’ for purposes of inducing an abortion.”
The memo then reviews diagnosis codes that are deemed acceptable for dispensation, which include miscarriage. “When dispensing a prescription for Misoprostol or Methotrexate to women of child-bearing potential in states that prohibit dispensing medications for the purpose of inducing abortion, Pharmacists should validate that the intended indication is not to terminate a pregnancy.” That includes not filling the prescription if it doesn’t have a diagnosis code, until they confirm it with the prescribing doctor. If they find abortion is the intended use, they “must refuse to fill the prescription.”
In addition to the guidance, the memo said that new warning systems would be implemented in CVS’s computers beginning July 1. “An alert will display at Data Entry Verification informing them to validate that the indication of diagnosis is documented on the prescription and that it is not to terminate a pregnancy.”
When asked for comment about the memo, Mike DeAngelis, the executive director of corporate communications at CVS, affirmed that “before filling a prescription for methotrexate or misoprostol in certain states, we’ve instructed our pharmacists to validate that the intended indication is not to terminate a pregnancy. Our highest priority is ensuring safe and timely access to medications for our patients, and we understand the important role pharmacies serve in support of women’s health care. We encourage providers to include their diagnosis on the prescriptions they write to help ensure patients have quick and easy access to medications.”
Requiring a diagnosis code to dispense a medication is not typical, Rebecca told me. She said that before receiving this guidance, she’d dispensed misoprostol countless times, no questions asked. Now she says she won’t unless she has a diagnosis code affirming such drugs won’t be used for an abortion.
Sometimes diagnosis codes are required by specific insurance companies, such as Medicare part B, for durable medical equipment, the dispensation of methadone and suboxone, or expensive medications. But most routine medications don’t require this information as part of a doctor’s prescription. And the new guidance had nothing to do with insurance coverage; instead, it was a direct response by CVS to the Supreme Court decision.
“I am torn on a regular basis between doing what is right by my patient and being sued because people who don’t understand health and medicine are making the rules,” Rebecca said. “I see these people on a daily basis; people in power do not.”
Some states, such as Louisiana, are also now, or soon will be, requiring a diagnosis code to ensure a medication is not being used for abortive purposes. This kind of legal interference for these medications is new, said James, a pharmacist working in South Carolina, North Carolina, and Georgia, who also did not want his real name used. “A state regulator coming into the equation essentially saying, ‘It’s illegal for you to dispense this drug for any purpose other than [x]’ is pretty much unprecedented, other than methadone and suboxone.”
As Dr. Katie McHugh, an ob-gyn in Indiana specializing in pelvic pain, said, “We know that any kind of legal interference in health care tends to worsen discrimination. It tends to further divide between socioeconomic classes, between racial groups, and these kinds of legal interferences tend to worsen health care outcomes for historically oppressed populations.”
There are sure to be challenges to these kinds of restrictions that make it harder for patients to get the medications they need, even if they aren’t being used for abortive purposes. This week, the Health and Human Services Department Office for Civil Rights released new guidance stating that pharmacists cannot turn away patients with prescriptions for medications that can end a pregnancy, including methotrexate, misoprostol, and mifepristone. This new directive would presumably supersede any laws surrounding pharmacists’ rights to refuse to fill a script for reasons of “conscience,” which exist in certain states.
Despite the administration’s response, Rebecca said, CVS has not updated the memo it sent or given additional guidance to its pharmacists. “I haven’t heard anything since that initial memo,” she noted. “I don’t know if they would change anything, since I am in a very strict state where fines and prison time [are] the punishment. They want to make sure we cover our asses.”