Insulin must be injected using a pen or syringe and is prescribed in variable units tailored to each patient's needs.
Seventeen states allow pharmacists to give patients a 30-day supply or the smallest complete package of insulin.
MO limits emergency prescription refills to seven days, which excludes the prescribable amount of insulin.
Insulin is a hormone the body produces to use or store sugar from food for energy which is necessary to live (American Diabetes Association 2025). People with diabetes no longer make or cannot use insulin effectively. Insulin cannot be taken by mouth and must be injected (Insulin Safety Center 2025). Insulin can be taken as a prefilled pen, a syringe and vial, a wearable pump with a cartridge, a patch, or a “pod” (Figure 1). A prefilled pen or a syringe and vial are the most common methods of administration (Sarkar et al. 2021).
Insulin comes in multi-day containers, like a vial or a box of pens (McKee et al. 2023). Doctors prescribe the amount of medicine to inject, and how often, and pharmacists dispense the full, sealed container(s) needed to meet the patient’s prescription. The Food and Drug Administration (FDA) advises pharmacists to keep the original packaging sealed, especially for insulin pens, until it is dispensed to the patient (FDA 2019). Pharmacists cannot open a sealed box of pens or split a single vial to give a patient a small amount, they must dispense the entire, sealed package.
Figure 1. Devices used to administer insulin. Different ways people take their insulin: pumps, vials with syringes, and prefilled pens. These containers are designed to hold a multi-day supply of insulin. Because the packaging size is fixed, laws that only allow a short, seven-day emergency refill cannot provide a patient with the whole, sealed container. Many states allow a pharmacist to dispense the smallest complete package or a 30-day supply. Figure from Insulin Safety Center 2025.
Some older forms of insulin are available without a prescription (Durham-Humphrey Amendment 1951). However, these preparations can lead to health problems because they lack the individualized use instructions that come with a prescription (Goldstein et al. 2018).
Because people can die if they run out of insulin, many states have passed laws to specifically address emergency insulin refills. OH and FL were the first states to pass these laws in 2016. Nineteen other states (AL, AR, AZ, CO, CT, ID, IL, IN, KY, OK, OR, PA, RI, SC, SD, TN, UT, WI and WV), have since followed suit. These states’ emergency insulin refills allow pharmacists the option to dispense either a minimum 30-day supply of the of the patient’s delivery method, typically one standard sealed box of insulin pens or one vial (FDA 2019).
During the COVID-19 pandemic, three other states (MA, NV, NM) and DC used executive orders to change their general emergency refill rules. Pharmacists were able to give a greater amount of medication in an emergency, including insulin.
RSMo 338.200 allows a licensed pharmacist to give an emergency medicine refill if they cannot reach the patient’s doctor. The pharmacist must have filled that medicine for the patient before and confirm that stopping the medicine would greatly harm the patient's health. The pharmacist cannot give an emergency refill for controlled substances. For non-controlled substances, the pharmacist can give up to a seven-day supply. The pharmacist must contact the prescribing doctor within 72 hours of dispensing the emergency refill, and inform the patient a new prescription is needed (State Code of Regulations 2025). Because standard packaging sizes (like vials or pens) for insulin contain more than a seven-day supply, pharmacists cannot dispense it as an emergency refill (McKee et al. 2023).
Legislators have filed bills in MO (HB 2455 in 2024, and HB 471 and HB 1188 in 2025) that would allow a pharmacist to dispense an an emergency refill amount equal to the most recent prescription or the standard packaging size.
References
Alabama Administrative Code r.504-X-4-.07 (2024). URL Link
American Diabetes Association (2025) Insulin Basics for Diabetes. URL Link
Arizona Administrative Code R4-23-412 (2025) URL Link
Arkansas Code Annotated § 17-92-102 (2023). URL Link
Colorado Revised Statutes § 12-280-125.5 (2019) URL Link
Commonwealth of Massachusetts. Executive Order for Practice of Pharmacy (2020). URL Link
Connecticut General Statutes § 20-616 (2021). URL Link
District of Columbia Mayor’s Order A23-247 (2020). URL Link
Durham Humphrey Act. Pub L No. 82-215, 65 Stat 648 (1951). URL Link
Florida Statutes § 465.0275 (2016) URL Link
Food and Drug Administration (FDA) (2019) FDA advises health care professionals and patients about insulin pen packaging and dispensing. U.S. Department of Health and Human Services. URL Link
Goldstein JN, McCrary M, Lipska KJ (2018) Is the Over-the-Counter Availability of Human Insulin in the United States Good or Bad? Journal of the American Medical Association. URL Link
HB 2455, 102nd General Assembly, 2nd Regular Session. (MO 2024). URL Link
HB 471, 103rd General Assembly, 1st Regular Session. (MO 2025). URL Link
HB 1188, 103rd General Assembly, 1st Regular Session. (MO 2025). URL Link
Idaho Statutes § 54-1735 (2024). URL Link
Illinois Compiled Statutes § 225-85/15.3 (2017). URL Link
Indiana Code § 25-16-13-25 (2019). URL Link
Insulin Safety Center (2025) Administration of Insulin. Institute for Safe Medication Practices. URL Link
Kentucky Revised Statutes § 315.500 (2010). URL Link
McKee AM, Yancey AM, Zhang RM, McGill JB (2023) The Nuances Surrounding Insulin Prescribing. American Diabetes Association, 41(3): 411-419. URL Link
Nevada State Board of Pharmacy. Guidance on the Authority of a Pharmacist to Issue Emergency Refills in Response to COVID-19 (2020). URL Link
New Mexico Statutes Annotated § 61-11-2 (2020). URL Link
Ohio Laws and Administrative Rules § 4729.281 (2022) URL Link
Oklahoma Statutes § 59-353.20.2 (2019). URL Link
Oregon Administrative Rules § 855-041-1120 (2018). URL Link
Purdon’s Pennsylvania Statutes § 390-1 (2018). URL Link.
Revised Missouri Statutes § 338.200 (2016). URL Link
Rhode Island General Laws § 5-19.1-37 (2025). URL Link
Sarkar S, Heyward J, Alexander GC, Kalyani RR (2021) Trends in Insulin Types and Devices Used by Adults with Type 2 Diabetes in the United States, 2016 to 2020. JAMA Network Open. URL Link
South Carolina Code of Laws Unannotated § 40-43-86 (2017). URL Link
South Dakota Administrative Rules § 20:51:05:20 (2024). URL Link
State Code of Regulations (2025) Division 2220 – Stated Board of Pharmacy. Secretary of State. URL Link
Tennessee Code Annotated § 63-10-207 (2018). URL Link
Utah Code § 58-17b-607 (2020). URL Link
West Virginia Code Article 5 §30-5-36 (2019). URL Link
Wisconsin Statutes § 450.11 (2020). URL Link
