Pharmacy at the Front Lines: How State Standing Orders Strengthen Health Resilience

By Vanessa Muller, PharmD

Introduction

When public-health rules shift, pharmacies often become the steady, familiar places people turn for timely guidance. Over the past several years, from COVID-19 surges to mpox outbreaks to shifting preventive-service coverage, communities have navigated rapid uncertainty. Through all of it, one quietly powerful tool has helped keep care accessible: State Standing Orders.

Standing Orders are statewide clinical protocols that allow pharmacists and other trained clinicians to provide certain services, vaccines, naloxone, contraception, or COVID/flu test-and-treat, without needing an individual prescription each time. They rarely make headlines, but they act as a kind of public-health infrastructure: simple, standardized tools that keep services available even when insurance rules fluctuate or primary-care access is limited.

What State Standing Orders Do

Standing Orders are created at the state level, usually by health departments or medical boards. They specify the service, clinical steps, training required, and how documentation must be handled.

Pharmacists in every state can administer at least influenza vaccines, though age limits and product lists vary. Other commonly covered services include routine immunizations, emergency naloxone, hormonal contraception (in some states), HIV PrEP/PEP initiation, test-and-treat for respiratory viruses, and point-of-care screenings.

While each state’s Standing Orders differ, a true patchwork, the national trend has been to expand pharmacist authority so that communities have accessible, flexible entry points to care.

 How Standing Orders Strengthen Health Resilience

Standing Orders matter most when the healthcare system is stressed. They support health resilience in three key ways:

1. Rapid Surge Capacity

Standing Orders were one reason many states could quickly mobilize COVID-19 vaccination and testing, and later respond to mpox outbreaks. Pharmacies already had standardized protocols and training in place.

During the COVID-19 rollout, pharmacies delivered a substantial share of adult COVID-19 vaccinations, including more than two-thirds of bivalent booster doses, according to the Federal Retail Pharmacy Program. That scale was only possible because pharmacists were operating under Standing Orders that enabled consistent, rapid service delivery.

 2. Continuity When Rules Change

Insurance coverage and preventive-service policies can change quickly. During these periods, Standing Orders help maintain practical, on-the-ground access. Even when coverage is unsettled, pharmacies can continue vaccinations and screenings using state-authorized protocols.

Regional collaborations, such as the West Coast Health Alliance, use shared communication playbooks to help pharmacies and clinics stay aligned when national guidance fluctuates.

3. Reaching Underserved Communities

Standing Orders are especially meaningful in rural areas, where patients may face long wait times or limited access to primary-care clinicians. Pharmacies often provide extended hours, walk-in care, and language-concordant staff, making them essential access points.

 A recent rural-health survey found that adults in many rural counties are more likely to receive vaccines in pharmacies than in physician offices, underscoring how Standing Orders help close geographic access gaps.

Standing Orders allow those access points to offer not just products, but guideline-based clinical care.

Case Snapshot

A 32-year-old patient recently moved and has not yet established care with a primary-care provider. Her insurance plan is still transitioning. When she hears about rising respiratory illness in her community, she stops at a local pharmacy, the only place open after 6 p.m.

Using the State’s Standing Order, the pharmacist screens her, administers both flu and COVID-19 vaccines, updates the state registry, and provides follow-up guidance.

A temporary insurance gap could have delayed her care. Instead, a Standing Order ensured timely access.

Gaps and Limits

Standing Orders are powerful, but their implementation varies widely. Differences include:

• Which services are authorized

• Eligible age groups

• Documentation and reporting requirements

• Training expectations

• Reimbursement structures

Reimbursement remains one of the most significant challenges. Even when pharmacists are legally permitted to provide a service, low or uncertain payment can make it difficult for smaller or rural pharmacies to offer it consistently.

 Independent pharmacies may also face challenges with staffing, reporting systems, or point-of-care testing equipment. Without support, Standing Orders may be easier for large chains to implement, risking unintentional disparities.

 Standing Orders sit alongside other tools such as statewide protocols and collaborative practice agreements; together, they make up the broader continuum of pharmacist prescriptive authority.

What Policymakers and Health Systems Can Do

For state legislators, regulators, and health-system leaders, several practical steps can strengthen Standing Orders as a resilience tool:

1. Modernize and harmonize Standing Orders

Ensure pharmacists statewide can provide a minimum set of essential adult vaccines and preventive services so that coverage gaps do not translate into access gaps.

2. Align reimbursement with clinical work

Pharmacies should be compensated for providing clinical services, not only for dispensing.

3. Improve integration with public-health data systems

Better interoperability with immunization and surveillance systems strengthens outbreak response.

4. Include pharmacists in regional preparedness planning

Pharmacists play a frontline role during surges; preparedness initiatives should reflect this.

5. Support small and rural pharmacies with implementation resources

Mini-grants for reporting systems or standardized Standing Order templates can make adoption more feasible and equitable.

Conclusion

Standing Orders rarely make news, but they quietly keep healthcare accessible during moments of uncertainty. They allow pharmacies to act quickly, maintain continuity when rules change, and offer care in communities that may otherwise go without preventive services.

Strengthening Standing Orders, through clear laws, sustainable reimbursement, and practical infrastructure support, helps build a more resilient and equitable health system for everyone.

References

1. National Alliance of State Pharmacy Associations (NASPA). Pharmacist Authorities by State. https://naspa.us/resource/scope-of-practice/

2. CDC. Federal Retail Pharmacy Program for COVID-19 Vaccination. https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html

3. American Pharmacists Association (APhA). State Immunization Authority Overview. https://www.pharmacist.com/Practice/Patient-Care-Services/Immunization

4. Journal of the American Pharmacists Association (JAPhA). Pharmacist-prescribed contraception. https://www.sciencedirect.com/journal/journal-of-the-american-pharmacists-association

5. CDC Standing Orders Templates. https://www.cdc.gov/vaccines/hcp/admin/standing-orders/index.html

6. Washington State DOH. Immunization Standing Orders. https://doh.wa.gov/immunization

7. Oregon Health Authority Pharmacist Protocols. https://www.oregon.gov/oha/Pages/default.aspx

8. Reuters. Regional Vaccine Alliances. https://www.reuters.com/

Assessed and Endorsed by the MedReport Medical Review Board