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Provider Status: What is it?

By: Katharine Russo, PharmD Candidate c/o 2021

             As of July 1, 2000, the Accreditation Council for Pharmacy Education (ACPE) mandated for the Doctor of Pharmacy (PharmD) degree to be the sole degree required to enter pharmacy practice in the United States. ¹ With this advanced degree came the complex education, training, and clinical practice experience to ensure entrusted health professionals were entering the field of medicine. Pharmacists are highly trained upon graduation and many continue on to complete additional training in fellowships and residencies and hold board certifications to specialize. This advanced training gives pharmacists the skills and training to properly manage chronic disease states, coordinate medications during care transitions, drug therapy management, offer counseling and education for preventative screenings, and give vaccinations. However, even with this education and training, pharmacists are still unable to practice to the fullest extent of their degree. Why is this profession limited? Pharmacists in many states across the US, including New York State, are limited in practice due to lack of provider status.

Provider status refers to being able to participate in Part B of the Medicare program and bill Medicare for services that are allowed under scope of practice. Currently, the federal government does not recognize pharmacists as health care “providers”. Therefore, pharmacists’ patient care services are not included in key sections of the Social Security Act (SSA), which determines eligibility for health care programs like Medicare Part B. Medical professionals that are currently listed as “providers” under the SSA include physicians, physician’s assistants, certified nurse practitioners, clinical social workers, and certified nurse midwives among others. ²,³ What does this mean for patients, especially those in medically underserved areas? Medicare beneficiaries are not able to receive patient care services by pharmacists like diabetes management, smoking cessation, and even annual wellness visits, which continues to potentiate gaps in healthcare. ⁴

While not federally recognized, some progressive states like California, Washington, and Idaho recognize pharmacists for their training and have expanded their scope of practice. Pharmacists in California have had prescriptive authority since the California Health Manpower Pilot Projects in 1972. The resultant success of these projects led to the passage of California Assembly Bill 717 expanding pharmacists authority in areas such as anticoagulation and drug dosing. Continued success of pharmacists’ efforts in practice paved the way for the 1981 passing of legislation that lead to pharmacists in acute-care settings (ie. inpatient hospitals) the ability to adjust dosages pursuant to a prescriber’s authorization, order drug therapy-related lab tests, and order or perform routine drug therapy-related patient assessments like diabetic foot neuropathy screenings. A year later, pharmacists’ roles were expanded again with the authorization to initiate therapy pursuant to a prescriber’s order. In 1994, ambulatory care clinics were an added area of pharmacy that pharmacists were allowed to exercise their authority. 

The year 2013 turned out to be one of the biggest steps for pharmacists the country had seen. Around the time the Affordable Care Act was passed, the State of California passed Senate Bill 493 allowing pharmacists to expand their scope of practice in the community setting. The expanded scope of practice allowed pharmacist to help primary health care providers who were inundated and overwhelmed by the influx of newly insured patient. This bill specifically added to the pharmacists’ functional authority the ability to, “furnish self-administered hormonal contraceptive, nicotine replacement products, and prescription drugs recommended for international travelers that do not require a diagnosis… order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies, and to now independently initiate and administer routine vaccinations, as specified”. ⁵ Prior to this law, community pharmacists already had the authority to administer, oral or topical, drugs and biologicals pursuant to a prescribers’ order, administer immunizations under a non-patient specific order, and provide emergency contraception under a non-patient specific order with completion of training.

The greatest advancement for pharmacists in 2013 was when Senate Bill 493 established the State Board of Pharmacy recognition for a new pharmacist licensure known as the Advanced Practice Pharmacist (APP). The APP licensure allows pharmacists to be recognized as a provider eligible for reimbursement services. Application for this license is not available to all pharmacists. Criteria for application includes two of the following: (1) certification in a relevant area of practice, (2) completion of postgraduate residency program, and (3) experience earned associated with the provision of 1,500 hours of clinical services to patients under a collaborative practice agreement or protocol within 10 years of the time of application. Three years later in 2016, California pharmacists were finally granted provider status; Assembly Bill (AB) 1114 mandated the rate of reimbursement for pharmacist provider services at 85% of the fee schedule for physician services under the California Medicaid (Medi‐Cal) program. However, the AB 1114 reimbursement scheme applied only to specific activities such as contraception, nicotine replacement, travel medicine, naloxone, and vaccinations.5  Under APP credentials, pharmacists are able to perform patient assessments, order and interpret all drug therapy-related tests, refer patients to other providers, operate as a collaborative drug therapy management pharmacist outside of an inpatient setting, and initiate, adjust, and discontinue drug therapy pursuant to an order by a patient’s treating prescriber and in accordance with established protocols.6

In the United States, 311,200 pharmacists were gainfully employed in 2019. ⁷ In 2019, 45% of U.S. adults between the ages of 19-64 were inadequately insured resulting in gaps in healthcare. ⁸ The World Health Organization (WHO) addressed the world in 2011 about the role pharmacists can play in closing global health care gaps, “…pharmacists could play their part in bridging the health gaps by using their clinical skills and by teaching them to others, by promoting the professional identity and esteem of pharmacists in developing countries, by promoting and being concerned about rational drug use rather than just medicines information, and by being concerned about therapeutic outcomes rather than just drug usage”. ⁹ Expanding the role of pharmacists across the country and world will lead to significant improvement of healthcare outcomes. In 2015-2016, according to the National Health and Nutrition Examination Survey, 45.8% of the US population used at least one prescription drug. ¹⁰ Medication use among Medicare beneficiaries is even higher; nearly half of Medicare users take at least 4 medications per day. ¹¹ Improving healthcare outcomes often goes hand-in-hand with cost efficacy. Proper use of medications is essential to improving outcomes and reducing cost, something that pharmacists have shown a great impact in doing. ¹² Medication nonadherence costs the healthcare industry an estimated $100 billion annually. Pharmacists can play a major role in driving down these costs by targeting the underlying root of the problem. Our advanced training allows us to optimize drug therapies, reduce bill burden when possible, aid in finding affordable and effective medications, and educate patients about their often complicated drug regimens. ¹³

The advanced training of pharmacists and their extensive drug therapy expertise makes them highly valuable in the medical field. Lack of recognition as providers has severely impacted practice and continues to prohibit patients from getting the healthcare they need. There are many ways to get involved, join the thousands of pharmacists and student pharmacists paving the way for the profession to achieve provider status.


  1. Accreditation Council for Pharmacy Education. https://www.acpe-accredit.org/about/
  2. The Pursuit of Provider Status: What Pharmacists Need to Know. American Pharmacists Association. https://www.pharmacist.com/sites/default/files/files/Provider%20Status%20FactSheet_Final.pdf. Published 09/01/2013.
  3. Cornell Law. 29 CFR 825.125-Definition of health care provider. . Legal Information Institute. https://www.law.cornell.edu/cfr/text/29/825.125. 
  4. Weaver K. Provider Status. Minnesota Pharmacists Association . https://www.mpha.org/page/journal_16_spring10/Provider-Status.htm. Published 05/31/2016.
  5. Guglielmo BJ, Sullivan SD. Pharmacists as health care providers: Lessons from California and Washington. J Am Coll Clin Pharm. 2018;1:39–44.https://doi.org/10.1002/jac5.1035
  6. Advanced Practice Pharmacist Certificate Program. California Pharmacists Association. https://cpha.com/ce-events/certificate-training-programs/app-faqs/.
  7. Occupational Employment and Wages, May 2019. U.S. Bureau of Labor Statistics. https://www.bls.gov/oes/current/oes29
  8. Collins S, Bhupal H, Doty M. Health Insurance Coverage Eight Years After the ACA. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca. Published 02/07/2019.
  9. The Society: Pharmacists can help close global health care gaps. The Pharmaceutical Journal, Vol 267 No 7168 p470-481. https://www.pharmaceutical-journal.com/the-society-pharmacists-can-help-close-global-health-care-gaps/20005162.article. Published 10/06/2001.
  10. Martin C, Hales C, Gu Q, Ogden C. Prescription Drug use in the United States, 2015-2016. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db334.htm. Published 05/31/2019.
  11. Obtaining Value Recognition and Compensation of Pharmacists Clinical Services. American Pharmacists Association. https://www.pharmacist.com/obtaining-value-recognition-and-compensation-pharmacists-clinical-services. Published 01/06/2013.
  12. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice: A Report to the U.S. Surgeon General 2011
  13. Pittman T. Medication Nonadherence Increases Health Costs, Hospital Readmissions. Duke Health. https://physicians.dukehealth.org/articles/medication-nonadherence-increases-health-costs-hospital-readmissions. Published 11/2/2018.

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