Prescription restrictions on hydroxychloroquine among the largest Florida pharmacy chains during the COVID-19 pandemic: An observational study

To the Editor: Hydroxychloroquine has long been used by dermatologists in the treatment of chronic disease, with use across such broad conditions as connective tissue disease, sarcoidosis, to lichen planopilaris. The medication has generally enjoyed wide availability at a more affordable cost. Earlier this year, hydroxychloroquine became a household name after political leaders touted the drug's efficacy in the treatment and postexposure prophylaxis of COVID-19. As demand for hydroxychloroquine grew, pharmacies reported shortfalls in supply and began implementing restrictions on dispensation.¹ Our study seeks to characterize these restrictions in Florida-based locations of the nation's most profitable retail pharmacies.

The 6 largest pharmacies with locations in Florida (CVS, Walgreens, Walmart, Humana, Publix, and Costco) and 2 mail-order pharmacy companies (Cigna-Express Scripts and Optum Rx by UnitedHealth) were identified based on total prescription dispensing revenue in 2019.² April 2020 policies regarding dispensation limits for new prescriptions of hydroxychloroquine and prescription refills were obtained from online data, where available. Otherwise, dispensation limits were obtained by phone from corporate offices and, when redirected, confirmed with at least 3 local pharmacists at different locations.

Restriction limitations, when applicable, for new hydroxychloroquine prescriptions and prescription refills are summarized in Table I . All pharmacies had strict limitations that prohibited new prescriptions in excess of a 14- or 30-day supply. Three pharmacies also reduced prescriptions for refills to 30-day supplies at a time (Fig 1 ). Our study identifies impacts to hydroxychloroquine prescribing practices in Florida's largest markets. It is a limitation of this study that only the largest pharmacy chains in the United States by revenue with locations serving Florida were evaluated.

Table I.

Pharmacy prescription restrictions for hydroxychloroquine

Pharmacy	Total prescription dispensing revenue in 2019 across all drugs3	Restrictions—patients requiring new prescriptions	Restrictions—refills for patients with established prescriptions
CVS Health	$109 billion	14-day supply∗	90-day supply†
Walgreens	$84.3 billion	14-day supply‡	30-day supply†
Cigna/Express Scripts	$45.8 billion	30-day supply†,§	90-day supply†,§
UnitedHealth Group OptumRx	$25.8 billion	30-day supply†,§,¶	90-day supply†,§
Walmart	$21.2 billion	30-day supply†	90-day supply†
Humana Pharmacy Solutions	$6.9 billion	30-day supply†	30-day supply†
Publix	$4 billion	30-day supply†	30-day supply†
Costco Wholesale Corp.	$2.7 billion	14-day supply‡	90-day supply†

^∗Subsequent refills up to 90-day supply for US Food and Drug Administration–approved indications.

^†Prescriptions filled only for US Food and Drug Administration–approved indications.

^‡Subsequent refills limited to a 14-day supply.

^§Additional preauthorization required.

^¶Subsequent refills limited to a 30-day supply, up to 90 days with prior authorization.

Fig 1.

Prescription restrictions for hydroxychloroquine.

The increased demand for hydroxychloroquine during the COVID-19 pandemic has resulted in heightened scrutiny of prescriptions. Amid the increasing demand and restrictions, patients with chronic dermatologic and rheumatologic conditions may be at harm; Michaud et al³ suggest that rheumatology patients have already begun rationing their medication regimens against professional advice because of shortages.³

A major concern lies in patients with new diagnoses of inflammatory and autoimmune conditions who require new prescriptions of hydroxychloroquine, now subject to more stringent quantity limits. Currently available data regarding the efficacy of hydroxychloroquine in the treatment of COVID-19 are conflicting,^{4 , 5} and the durability of this new indication for hydroxychloroquine remains to be seen. If current market demand for hydroxychloroquine continues to exceed supply, and large national shortages for hydroxychloroquine continue to persist, subsequent prescription limitations may put dermatology patients at risk. Continued efforts should be made to ensure that medication is available for patients with chronic rheumatologic and dermatologic conditions that require hydroxychloroquine, including upholding proper prescribing practices by doctors. Dermatologists are called to self-police and limit prescriptions for hydroxychloroquine to those for dermatologic purposes. Dermatologists should also anticipate increased clarification queries on International Classification of Diseases codes and imposed quantity limits and will face local variance in supply. Compounding and nonchain pharmacies may serve as supplementary sources to meet increased demand. Dermatologists must be aware of, and adapt to, identifiable changes in the market for hydroxychloroquine for the benefit of their patients.