Wayne, New Jersey, ophthalmologist Donald J. Cinotti, MD, is accustomed to the usual delays with having orders filled promptly at area pharmacies. Those can relate to medication shortages, prior authorization and other insurance restrictions, or the occasional instances in which a pharmacist appropriately warns of a potential drug-patient or drug-drug interaction.
But Dr. Cinotti was taken aback when he heard from an ophthalmology colleague—a DO—in Central New Jersey that a pharmacist had refused to fill that doctor’s prescription because it was “outside the prescriber’s specialty.” Dr. Cinotti’s colleague had ordered a cream to treat a patient’s rosacea, which can increase the risk of the inflamed-eyelid condition blepharitis.
“Outside the prescriber’s specialty” for an ophthalmologist to order a medication for an eyelid condition? That seemed wrong to Dr. Cinotti.
Did the pharmacist perhaps mistake the ophthalmologist’s doctor of osteopathic medicine (DO) degree for the doctor of optometry (OD) degree—with optometrists of course being valued members of the physician-led team, but not permitted to order such medications? Was there a typographical error that led to some DO/OD confusion? No, and no.
As Dr. Cinotti and his colleagues in New Jersey investigated the matter, they discovered that other ophthalmologists, anesthesiologists and other doctors were encountering instances in which pharmacists appeared to substitute their judgment for the physician’s in refusing to fill orders for sedatives, anxiolytics or dermatologic agents.
“Such refusals contradict American Medical Association policy opposing pharmacists’ authority to initiate, modify or substitute medications outside a physician’s explicit direction, and amount to inappropriate intrusion into the practice of medicine,” Dr. Cinotti noted in a resolution that the American Academy of Ophthalmology introduced at the 2025 AMA Annual Meeting in Chicago. He serves as an alternate delegate for the organization in the House of Delegates.
“Pharmacists are not trained or licensed to make medical diagnoses and their scope of practice does not include the authority to override a physician’s clinical judgment or determine a patient’s treatment plan,” said the resolution, whose recommendations were adopted by delegates with a minor amendment.
“These denials disrupt patient care, compromise safety, delay medically necessary treatment and may create liability and access issues, particularly for patients with urgent or chronic conditions,” the resolution added.
Learn more with the AMA about what sets apart physicians and pharmacists.
More study needed
At the Annual Meeting, physicians’ testimony on the resolution “universally acknowledged that while pharmacists play an important role as part of a physician-led team, they should not have the authority to unilaterally withhold medication from patients after it has been prescribed by a physician,” a reference-committee summary noted.
To address the issue, delegates at the 2025 Annual Meeting directed the AMA to study the matter and its impact on patients and work with state medical boards and pharmacy boards on it. A report is likely to be issued at the 2026 AMA Annual Meeting in June.
With its action, the House of Delegates reaffirmed “existing policy opposing unauthorized medication substitution, inappropriate pharmacy inquiries and unauthorized treatment modification by pharmacists.”
The AMA also supports legislation or regulatory actions requiring pharmacists and pharmacy chains to either fill a valid prescription or immediately refer the patient to an alternative dispensing pharmacy, with notification to the prescribing physician.
The AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety. Both in Congress and at the state level, the AMA is pushing back on pharmacists’ efforts to inappropriately expand their scope of practice.
Building on AMA advocacy
The delegates’ latest actions build on existing AMA policy and ongoing advocacy efforts. In 2023, the House of Delegates adopted policy that “deems inappropriate inquiries from pharmacies to verify the medical rationale behind prescriptions, diagnoses and treatment plans to be an interference with the practice of medicine and unwarranted.”
Other supportive language on this issue is found in AMA policy on drug formularies and therapeutic interchange, generic drugs and therapeutic and pharmaceutical alternatives by pharmacists.
Meanwhile, the AMA has worked with state medical associations such as those in Illinois and Minnesota to ensure that physicians’ prescribing orders are not impeded. Those states have seen two of the more promising state laws recently enacted help protect patients who rely on opioid therapy. The Illinois law enacted in 2025 includes several important provisions, including:
- “Decisions regarding the treatment of patients experiencing chronic pain shall be made by the prescriber with dispensing by the pharmacist in accordance with the corresponding responsibility as described in 21 CFR 1306.04(a) and 77 Ill. Adm. Code 3100.380(a).”
- “Ordering, prescribing, dispensing, administering, or paying for controlled substances, including opioids, shall not in any way be predetermined by specific morphine milligram equivalent guidelines except as provided under federal law.”
And in 2024, Minnesota enacted a more comprehensive set of provisions that include:
- “No physician, advanced practice registered nurse, or physician assistant, acting in good faith and based on the needs of the patient, shall be subject to disenrollment or termination by the commissioner of health solely for prescribing a dosage that equates to an upward deviation from morphine milligram equivalent dosage recommendations or thresholds specified in state or federal opioid prescribing guidelines or policies, including but not limited to the Guideline for Prescribing Opioids for Chronic Pain issued by the Centers for Disease Control and Prevention and Minnesota opioid prescribing guidelines.”
- “A physician, advanced practice registered nurse, or physician assistant treating intractable pain by prescribing, dispensing, or administering a controlled substance in Schedules II to V of section 152.02 that includes but is not limited to opioid analgesics must not taper a patient's medication dosage solely to meet a predetermined morphine milligram equivalent dosage recommendation or threshold if the patient is stable and compliant with the treatment plan, is experiencing no serious harm from the level of medication currently being prescribed or previously prescribed, and is in compliance with the patient-provider agreement as described in subdivision 5.”
- “A physician's, advanced practice registered nurse's, or physician assistant's decision to taper a patient's medication dosage must be based on factors other than a morphine milligram equivalent recommendation or threshold.”
- “No pharmacist, health plan company, or pharmacy benefit manager shall refuse to fill a prescription for an opiate issued by a licensed practitioner with the authority to prescribe opiates solely based on the prescription exceeding a predetermined morphine milligram equivalent dosage recommendation or threshold.”
