Re: Hernandez Bustamante et al. “Pharmacist administration of long-acting injectable medications for substance use disorders”

Dear Editor,

We commend Pamela Hernandez Bustamante et al on their scoping review, “Pharmacist Administration of Long-Acting Injectable Medications for Substance Use Disorders” (Ment Health Clin. 2025;15(1):17-24). This critical work highlights the potential for pharmacists to enhance access to long-acting injectable buprenorphine (LAIB) for substance use disorders. The authors note a gap in research on pharmacist-administered LAIB and recommend standardizing training, developing operating procedures, and addressing billing and reimbursement issues to support widespread implementation.

In North Carolina, pharmacists gained the authority to administer long-acting injectable (LAI) medications in October 2021 with North Carolina Medicaid reimbursing them for injection administration at $17.36 per injection. A collaborative team from North Carolina Medicaid, Tailored Plans, and the state pharmacy association has been exploring methods to facilitate LAIB administration in pharmacies. Some pilot pharmacies, previously using nurses for LAI antipsychotic injections, now administer LAIB, following clarification from the North Carolina Board of Pharmacy. A 2024 study by our team on pharmacy-based administration of LAI psychotropic medications included 614 administrations, 13 of which involved LAIB. This pilot study is nearing completion and aims to develop a sustainable reimbursement model for pharmacy-based administration of all long-acting behavioral health medications.

Despite these advances, several barriers hinder widespread LAIB administration in pharmacies. Whereas North Carolina Medicaid reimburses pharmacists for injection administration, many other insurers do not, leaving pharmacies to absorb financial losses, especially when serving non-Medicaid patients. Additionally, pharmacies must be Risk Evaluation and Mitigation Strategy registered to purchase LAIB products, and without specialized contracts, pharmacies face inadequate reimbursement rates below cost. Even with reimbursement above cost, the profit margin is minimal, particularly for small independent pharmacies. Many pharmacies also face challenges with delivering LAIB products to prescriber offices, incurring costs not fully covered by Medicaid, which further deters pharmacies from offering these services.

To overcome these barriers, we agree with the authors’ recommendation to clarify billing and reimbursement policies, which vary by state. Raising awareness among pharmacists of their legal authority to administer LAIB is also critical. Furthermore, all payers should reimburse pharmacies for injection administration with rates reflecting the time, resources, and costs involved in providing this service. Reimbursement should cover expenses and provide incentives for pharmacies to offer LAIB administration, reducing waste compared with white bagging. The potential for waste occurs with white bagging when the pharmacy ships the medication to the provider for administration, but the patient does not present for the appointment, there is a dosage change or side effect, or there is another event that leads to the medication not being administered. In this case, the medication has been billed to the health care plan and is not easily returned and credited. With pharmacist administration, the medication is not billed until administration, eliminating this waste potential.

To make this collaborative model work and improve access to behavioral health LAIs, it is crucial to address these financial and logistical challenges and ensure sustainable and scalable reimbursement practices.