To determine the benefits of engaging in a CPA, first consider your proposed specific CGM service and what it entails. There are a number of elements and factors you will want to consider when exploring a CPA.

State regulations and requirements

While all 50 states and the District of Columbia allow pharmacists to enter into a CPA, regulations regarding CPAs and specific requirements are highly variable. Your state may dictate that only certain types of providers can serve as the supervising provider or may dictate that a CPA can only cover specific patients. Be sure to check if there are any requirements to submit CPAs or protocols to your state board for review or approval. At the very least, make sure to have a copy of any CPAs available within your pharmacy for board inspection or review, if requested. See the [insert link to regulatory document describing CPAs here] resource for detailed information about CPAs in your state.

State authority to perform CGM and associated services

The first question you should ask yourself when reviewing your state-specific regulations and requirements is “Do I have the authority as a pharmacist to perform CGM services and any associated medication management under my state’s pharmacy practice act?” If the answer to this question is no, then you will need to leverage a CPA to offer these services to patients.

CGM billing considerations

If your state does allow pharmacists to perform these services, you may or may not need a CPA. If this is the case, you’ll want to ask yourself, “Can I bill for CGM monitoring services directly?” If you cannot, then you may need a CPA if you are interested in billing insurance and third-party payers as part of an incident-to model encounter. If, on the other hand, you only plan to accept cash payments, and you have already established that your state’s scope of practice includes CGM services, you may not need a CPA. Even if this is the case, there may be some notable advantages of engaging in a CPA—continue to Step 2 for these considerations.

Game plan in action: Step 1: The pharmacist reviews the state regulations in Wisconsin and learns the Wisconsin Statutes Chapter 450 allows pharmacists to administer prescribed drugs and devices, which would cover activities like sensor placement and patient education for CGM devices. The statute, however, does not explicitly list CGM monitoring as a standalone service though, so the pharmacist assumes they will likely need a CPA for interpretation of CGM and associated therapy adjustments for patients participating in monitoring visits. Digging into the Medicaid requirements a bit more, the pharmacist understands they are recognized as a nonphysician provider under Medicaid and can independently bill for CGM setup and training, but a CPA will be required for initiation or modification of therapy. Additional requirements that apply to CPAs for Medicaid require that both the pharmacist and provider must be enrolled in Wisconsin Medicaid and the pharmacist will have to attest to working under a CPA during the enrollment process. This is good news for the pharmacist, since their pharmacy provides services to a large Medicaid population, and they will be able to bill Medicaid for CGM services under the medical benefit using the appropriate CPT codes.

Once you decide to move forward with a CPA to support your CGM pharmacists’ service, you will need to identify an appropriate collaborating provider to co-manage patients enrolled in the program. You should be intentional about which providers you will collaborate with, as they will be an extension of your service and can influence which patients you will manage, as well as the scope of services you will provide.

Ideally, you will want to identify local providers within your immediate area who manage your target patient population, which in this case are patients with diabetes who are eligible for or would benefit from a CGM. You may choose to start identifying providers within certain specialties, such as primary care, endocrinology, and/or possibly even obstetrics and gynecology. Choosing providers with specialties that align with disease states targeted by your service will help to ensure more opportunity for patient referral and management.

When identifying providers to collaborate with, reflect on your value proposition and how your service can help to minimize or eliminate any known pain points experienced by providers in your area. For example, if a local provider is overwhelmed with the prior authorization requirements for CGMs enacted by payers and this is something your pharmacy regularly navigates throughout the dispensing process, the provider may be very willing to engage in a CPA to help them address the burden of navigating the prior authorization process, thereby increasing patient access to CGMs and improving patient satisfaction. Providers can benefit from increased efficiencies within their practice, and you can benefit from gaining access to additional patients for CGM services with the use of a CPA. The relationships and trust fostered by CPAs may result in additional opportunities to provide pharmacists’ services to your community, as both providers and patients come to rely on you for their care needs.

Moreover, providers who are held to certain quality standards for Medicare or other value-based care arrangements can benefit from the collaboration with a pharmacist through a CPA. Pharmacists engaging in CGM services are well positioned to provide education to help close important care gaps, such as medication adherence and A1C screening. By working with a pharmacist, patients may also be able to achieve lower A1C goals and reduce complications such as hospitalizations or emergency department visits. This results in better quality of life for the patient, lowered health care costs and utilization, and may also result in additional bonus payments for the provider.

In some cases, a CPA for CGM services may be a natural stepping stone to enhanced or additional services within diabetes therapy management. Pharmacists can bring tremendous value to providers, promoting effective and efficient utilization of health care resources by engaging in things like diabetes self-management education and support (DSMES), chronic care management (CCM), and/or remote patient monitoring (RPM) services. All of these services, reimbursable by Medicare, promote optimal patient outcomes and improve quality of care for patients.

It is never too early to consider forging relationships with potential collaborators. In fact, you may already have a strong foundation in place if you are proactive in helping to manage patients through your existing dispensing workflow. Don’t underestimate the importance of good clinical practice in helping to foster relationships with providers in your immediate area. Be intentional with the language you use when conveying recommendations for drug interactions, dose changes, and medication therapy optimizations to build trust with providers. Be mindful of the tone you use and highlight the value of a team-based approach, as it can go a long way in allowing you to be seen as a valuable partner throughout the medication use process. You may find that providers who reciprocate these values tend to be natural partners for the pursuit of CPAs.

Outside of the usual pharmacy workflow process, you can seek to engage with providers in multiple other ways. Consider creating quick-reference tools, decision aids, or education for common prescribing scenarios or utilization management situations. Going above and beyond in this way can showcase your clinical expertise and help to promote efficiency for the provider. It also helps to build providers’ reliance on your advice and guidance while also demonstrating that you are a true team player. Face-to-face conversations can also be extremely valuable, and you may consider visiting some of your local providers to better facilitate the creation and management of these professional relationships.

Be sure to tailor your communications to your audience and remember that different providers will have different things that are important to them. When engaging a primary care provider, you may wish to highlight some of the ways you can help their practice become more efficient through your CGM service. An endocrinology practice may be more interested in the attainment of optimal A1C values, improvement in TIR, or reduction in hypoglycemic events, while a primary care provider may simply want help educating their patients on CGM usage. Knowing what is important to each provider is critical, and this may also vary from practice to practice, even within the same specialty.

Game plan in action: Step 2: The pharmacist is familiar with a few primary care providers in the area through the usual course of dispensing. There is one provider, in particular, that the pharmacist knows well and often speaks directly to when receiving verbal prescriptions. The pharmacist frequently advises this provider on covered formulary options for their many Medicaid patients and thus has built a good amount of trust with this provider. The pharmacist decides this is a good provider to pursue entering into a CPA with. Knowing they have several mutual patients, the pharmacist decides to stop by the provider’s office one Thursday afternoon to introduce themselves and share a little bit about their CGM services. The pharmacist also knows of a busy local endocrinologist who has been in practice for a couple of decades. The endocrinology office frequently sends prescriptions for GLP-1 medications to the pharmacy, but the patients often struggle with which products are covered by their insurance as well as the prior authorization requirements. Recent shortages with increased demand of GLP-1 products have magnified this problem, so the pharmacist decides to put together some educational materials for the provider to help aid in GLP-1 prescribing, including information about covered formulary options and plans to send an update about current product availability directly to the endocrinologist’s office via fax on a weekly basis. The pharmacist hopes that this will help them become the pharmacy of choice for the practice’s patients with diabetes and eventually plans to approach the provider regarding its CGM services, which would be a natural extension of the existing diabetes care the pharmacy provides.

Required components of CPAs vary by state. General components of CPAs across states may include the following³:

1. Authority: Often the authority from a state’s pharmacy regulations can be cited to describe the rationale for allowing a pharmacist to perform certain activities under a CPA. Consider citing your state’s specific regulation or code in this section.
2. Party agreement/level of delegation or supervision allowed to conducut services: Some states require pharmacists to work under the direct supervision of a prescriber, particularly during the initial period of the CPA. Some states may have restrictions on prescribers that can enter a CPA (ex. physicians vs. mid-level practitioners). Moreover, this section will specify who is a party to the agreement and might name individual pharmacists or providers, or it could outline the parties to the agreement as pharmacists of a particular pharmacy or providers of a particular practice. Whenever possible, seek to create CPAs that utilize broad groups of providers (i.e. all of the providers at a given practice vs. just an individual provider). This will help to reduce the amount of work in creating separate CPAs for every provider at a practice. Likewise, whenever possible, include language in your CPAs for all pharmacists at a given practice (i.e. all pharmacists working at the pharmacy) vs. limiting to a specific pharmacist.
3. Malpractice coverage details: This section may specify who is responsible for maintaining liability insurance and in what amount. Refer to any state-specific regulations to determine if there are specific requirements for your unique scenario.
4. Education requirements: States may define what training and credentials are needed for pharmacists to enter a CPA. Some states mandate additional training (such as residency completion), registration or certifications (like board certification), years of pharmacy experience in the practice area, or continuing education for participation after initial implementation.
5. Scope of practice: The specific tasks pharmacists can perform under a CPA are often defined by state law and may include restrictions on initiating, modifying, or discontinuing drug therapy. This section will also typically include any disease states relevant to the CPA as well as a description of which patients are included. Some CPAs can be patient-specific, requiring the individual patient to be listed, while others may be more population-based, instead including a specific category of individuals that fits the criteria. Most states allow for broader population-based CPAs, so this is preferable wherever possible. State regulations also heavily dictate scope of practice elements for CPAs. When creating a CPA, you should aim to keep it at the broadest scope of practice that the collaborating provider(s) allows for; doing so will ensure that as the pharmacist you have the maximum possible impact on CGM outcomes and diabetes-related metrics. For example, with a CGM pharmacists’ service, you should consider adding the ability to initiate or change doses of insulin and other diabetes medications based on CGM results and patient conversations.
6. Enrollment/informed consent: It is important to include a description of how patients will be enrolled in the service as well as how informed consent will be obtained. Also be sure to capture if informed consent needs to be re-obtained annually or on another cadence and how patients can withdraw consent from the program.
7. Documentation processes: Ensure documentation processes are specified and meet state regulations. Often this section will include where documentation is to occur, which helps to ensure all parties are aligned on where to find information. Some states may require documentation to be immediately sent to provider or chart reviews conducted annually (or other specified time frame).
8. Reporting: This section outlines any situations that require immediate reporting or notification to a provider or other designee. This may include things like new patient complaints or changes in condition. For example, in a CGM service, the pharmacist may be required to report any known hypoglycemia events to the provider within 24 hours.
9. Quality assurance/quality improvement: Outlines what data will be utilized to track and monitor to ensure the highest quality of care is provided and any associated evaluations of the pharmacist, outcomes to be tracked, or patient satisfaction surveys.
10. Record retention: Outlines where records are to be kept and the duration of time that records must be kept available. Be sure to check any state-specific requirements for records retention schedules.
11. Follow-up communication: Establish clear protocols for follow-up communication with the provider. Any time limitations should also be included in this section.
12. Treatment protocols: This section may include various patient flows algorithms, diagrams, and/or guidelines to aid in the treatment protocol that will be followed. This section may also include details about when referrals are required and special scenarios that may arise. For CGM services, this section should also outline the type of CGM services that are provided—for example, whether the pharmacist is utilizing professional CGM service with a pharmacy-owned device or offering CGM services with the patient’s own personal device should be specific here.
13. Agreement duration and modification: This section outlines the terms of the agreement and how long the agreement is valid. It also details how any changes can be made to the agreement and if they need to be in writing and signed by all parties. This section may also include language about renewal of the agreement after a certain term.
14. References: References may be included to clinical practice guidelines, white papers, or other treatment resources relevant to the disease states being treated and the clinical service.
15. Disclaimers: CPAs may include disclaimers or other protective clauses to clarify responsibilities and limit liability. These disclaimers may also aim to ensure agreements are compliant with state laws.

Additional considerations may arise specific to your particular state or the provider you are working with. However, whenever possible, aim to keep service-specific CPAs as consistent as possible, leveraging the same or similar treatment protocols if you can. This helps to maximize efficiency in your workflow processes when the process is kept consistent throughout and does not vary across different providers or provider groups and also helps to keep the patient experience consistent. For a detailed review of the CPA requirements for your state, see the “CPA Requirements” resource.

Game plan in action: Step 4: The pharmacist’s lunch meeting with the local primary care provider was a successful discussion, and the pharmacist begins to research the required elements of a CPA in Wisconsin to present to the provider for initial draft. They locate the associated regulation that enables collaborative practice agreements through the Wisconsin Pharmacy Statutes and plan to include it in the CPA. Wisconsin regulations, specifically Act 294, allow a physician to delegate any patient care service to a pharmacist, provided it is within the pharmacist’s training and licensure, which allows a lot of flexibility within the CPA. When meeting, the provider and pharmacist agree to delegate the initiation or continuation of CGM devices and supplies to the pharmacist for any patient who is a current patient at the practice with an existing diagnosis of diabetes. The provider also agreed to delegate the ordering and evaluation of laboratory results for diabetic patients and the initiation, modification, or discontinuation of diabetes medication therapy for this same group of patients, with notification of changes being made in the EHR within 24 hours. For patients of the practice who have not been seen in over a year or who do not have a diagnosis of diabetes, the pharmacist will be required to refer the patient back to the office for follow up. The pharmacist includes a quality improvement section that details target outcomes metrics, such as A1C, for enrolled patients that will be reviewed in summary form every 6 months. A time frame of 2 years is utilized for the duration of the agreement, at which point the pharmacist and physician both plan to evaluate the current collaborative practice and consider any further adjustments to the protocol. The most recent ADA Standards of Medical Care in Diabetes is included in the treatment protocol and as a reference for the general approach the pharmacist will take to the initiation, modification, or discontinuation of current diabetes medication therapy management.

Finally, utilize the above elements and knowledge to put everything together in one place for your CPA. Both parties will need to be aligned with the terms of the agreement and ultimately, you will both sign to signify an understanding of the services that will be provided.

Even after you have an executed agreement in place, don’t underestimate the importance of continuing to build new and foster existing relationships with your local providers. Doing so can help open the door for additional future opportunities and expansions. Maintaining mutual respect and trust is necessary for continued success in any collaborative practice.

Please note that the sample CPA is intended to serve as an example and should not be implemented in other practice settings without proper adaptation. The CPA and protocol must be reviewed, updated, and approved by relevant entities to ensure compliance with local regulations and standards.

Access the CGM CPA template in the Downloadable Assets section.

Game plan in action: Step 5: The pharmacist utilizes the above research to create a draft CPA for CGM services to present to the physician. The physician is offered the chance to redline the draft, the pharmacist reviews the edits, and then once both parties are satisfied with the agreement, they sign and date to make it effective. They continue to work collaboratively both within the context of the CPA and through the usual course of the dispensing process and have regular check-ins at least every 6 months to assess how the program is going.

Appendix: Example ways to initiate conversation

The ability to handle rejection gracefully is important so that you can leave the door open for future opportunities. Stay positive and thank the provider for their time and consideration, saying something like, “I appreciate you taking the time to discuss this with me. I understand that now might not be the right time…” Follow up with a thank-you email summarizing the discussion and reiterating your interest in future collaboration. Rejection is common in these types of discussions, and maintaining a positive, open approach can help keep the door open for future collaboration. Acknowledge their concerns, reiterate the benefits of the CPA, and express your willingness to revisit the conversation at a later time. By remaining calm and understanding, you can build a relationship of trust and potentially pave the way for a future agreement when the provider feels more comfortable. Also be sure to continue to have a proactive approach in managing the provider’s patients on a day-to-day basis in an effort to continue to build the relationship and demonstrate where value can be added through effective collaboration.

Physicians may have limited knowledge of the specific state regulations pertaining to CPAs and where liability falls within an agreement. It's helpful to explain that pharmacists are trained professionals with the qualifications to perform certain tasks within the CPA framework. You may wish to clarify that liability is shared according to the CPA; once the pharmacist is acting within the scope of their training, the liability shifts to them, unless negligence is involved. This shift allows the physician to focus on their own duties and responsibilities, with the pharmacist taking on theirs.

Additionally, if a physician expresses reluctance, it may be beneficial to further discuss how CPAs can enhance patient care, make workflows more efficient, and clarify each provider’s role in a collaborative setting. Sometimes it may be possible to develop pilot programs or limited scope agreements with a small group prior to launching your full service offering with the provider. For example, for a CGM specific CPA prior to signing the full agreement, the provider may be willing to pilot a pharmacy driven recommendation-based service where the pharmacist takes charge in identifying patients eligible for the CGM and sends recommendations to the provider for what should be prescribed. The provider issues the prescriptions, and the pharmacist provides patient education and follow up. Once the provider is comfortable with this service, they may be more willing to sign a CPA to transfer prescriptive authority to the pharmacist and reduce the workload on the provider.