On a recent spring evening, Jessica Nouhavandi found herself at the National Abortion Federation conference, surrounded by abortion providers talking excitedly about one key question: how to expand access to medication abortion in more states.
Nouhavandi’s company, Honeybee Health, is a crucial part of that goal. Barely four years old, the online, California-based mail-order pharmacy start-up is already one of the nation’s leading distributors of abortion pills. At some point, one of Nouhavandi’s fellow conference attendees asked if she could have imagined this moment just a few years ago. Nouhavandi remembers shaking her head in disbelief, her voice growing stronger with an unexpected surge of pride. “It was a very emotional moment to think of how far we’ve come in such a short amount of time,” she says.
A few days later, Nouhavandi got emotional for a different reason. On May 2, Politico published a draft of a Supreme Court opinion that would overturn Roe v. Wade. Most abortion providers had been expecting the outcome, but the leaked draft confirmed their worst fears and focused the country’s attention on the stakes of the fight that abortion-rights advocates like Nouhavandi have been waging.
If the Supreme Court does overturn Roe, about half of U.S. states are expected to ban or severely restrict abortion. Advocates see medication abortion—a regimen of two drugs that can now be mailed directly to patients’ homes or to another location of their choosing—as key to the future of abortion access in the United States. Nouhavandi, 37, is leading that fight.
Nouhavandi is co-founder and lead pharmacist at Honeybee Health, the first mail-order pharmacy in the U.S. to ship abortion pills. It’s now one of just two American pharmacy companies doing so—six months after the FDA permanently removed a requirement that the pills be dispensed in person and more than a year after the agency said it would stop enforcing the regulation during the COVID-19 public health emergency. Honeybee now operates in 48 states and territories, and works with a wide range of providers, from independent abortion clinics to most of the major abortion telehealth startups, to primary care practices starting to prescribe abortion pills for the first time.
With her signature collection of colorful glasses and broad smile, Nouhavandi has become a familiar face and critical resource as providers and activists scramble to find creative ways to educate patients and clinicians about abortion pills before the Supreme Court’s final ruling, which is expected at some point in June or early July. “Every person should have the choice to do what’s best for them. And that’s not always the case with health care in our country,” Nouhavandi says. “But as long as there are still states that are protecting the right to abortion … we’ll continue to find ways to support people, especially those that need it most.”
New FDA regulations transformed access to abortion pills
When Nouhavandi and her co-founder Peter Wang launched Honeybee Health in 2018, abortion access was not particularly on their minds. They’d been operating a regular community pharmacy outside Los Angeles and thought a new, online, mail-order pharmacy could help lower prescription drug costs by offering generic medications from wholesalers without going through health insurance.
But in 2020, when coronavirus precautions made people want to stay home and orders from Republican state officials temporarily closed some abortion clinics, providers began exploring how they might get abortion pills to patients outside of a traditional office setting. While other medical appointments largely moved online, specific requirements for mifepristone, one of the two drugs involved in medication abortion, prevented clinics from using telehealth appointments or mailing the medication. So medical groups sued the FDA, asking the agency to allow them to mail the pills during the ongoing public health emergency. In July 2020, a federal district court judge in Maryland agreed, and temporarily suspended the in-person dispensing requirement, saying providers could offer telemedicine appointments and then mail the pills to their patients. (The Supreme Court later reinstated the regulation after a challenge from the Trump Administration, but the FDA said it would stop enforcing it last spring and then permanently removed it in December.)
The ruling was transformative for abortion-rights advocates. But for the first several weeks after the judge’s decision, providers weren’t sure how using a pharmacy would work since the FDA still imposed special requirements on the drugs, says Elisa Wells, co-founder and co-director of Plan C, which aims to increase information about abortion pills and advises many abortion providers.
“Everyone was working from home, so the providers we had been working with were getting [the pills] shipped to their homes, which were then their offices,” Wells says. “They were packaging them up themselves, and they were figuring out how to print labels. All this stuff that a pharmacy would normally do for you.”
One day, Wells was on a webinar where an ACLU lawyer said the court ruling should allow providers to contract with online pharmacies. A number of providers had already been in touch with Nouhavandi, and they started more serious discussions about how Honeybee could help. “It wasn’t even a question,” says Nouhavandi, who has long had an interest in reproductive health and access. “It was yes, absolutely, let’s figure out how to do this.”
Honeybee had to figure out every detail from scratch: how they would receive prescriptions, what directions to patients should say, what information pharmacists needed if patients called Honeybee with questions instead of their own clinician. Nouhavandi brought in abortion providers to help educate her staff.
The process wasn’t easy. For starters, few people knew about abortion pills. When Nouhavandi texted her group chat of college-educated friends that she was starting this new project, her peers said they’d never heard of medication abortion. Even in pharmacy school, Nouhavandi says, “it’s just not something that is extensively taught. So pharmacists must go out of their way to get up to speed.”
This lack of information was due in part to the restrictions that the FDA has put on mifepristone since the drug was first approved in 2000. Most notably, the FDA required it to be dispensed in a clinic, doctor’s office or hospital. Providers are also required to get specially certified to prescribe the medication, must counsel patients on the risks, and then have the patient sign a form confirming they’ve been told that same information. These steps, while each relatively small, collectively created regulatory barriers that providers argue are not medically necessary and do not exist for even some highly addictive drugs.
Abortion-rights activists, doctors, and researchers have spent years amassing data that shows medication abortion is safe and pushing for the government to treat it like other drugs with similarly low risks. They applauded the FDA’s December decision to remove the in-person dispensing requirement, but many were frustrated the agency didn’t go further. The FDA left the other requirements in place and added a new one: that pharmacies like Honeybee have to get certified to distribute mifepristone.
The FDA told TIME that after reviewing data and published literature about mifepristone, it concluded it was safe to get rid of the in-person requirement “provided all the other requirements of the [drug safety program] are met, and pharmacy certification is added.”
But the new certification requirement “came out of left field,” Nouhavandi says. One major wrinkle was that no certification process currently exists. Mifepristone’s manufacturers are working with the FDA to get a procedure approved, but that process could still take months.
In the meantime, the FDA has still paused enforcement of the in-person dispensing requirement during the pandemic public health emergency, and is allowing mail-order pharmacies to ship the pills as Honeybee has been doing. Amidst this confusing regulatory landscape, other larger pharmacies have not jumped to enter the market. TIME asked the five biggest pharmacy companies in the U.S. about whether they planned to seek certification, and most did not respond or declined to comment. CVS told TIME that retail pharmacies are not currently allowed to distribute mifepristone, and said it would review any changes from the FDA in the future.
Nouhavandi says she expects that some of the larger companies are “probably not wanting to touch this subject.” That’s been a boon to Honeybee’s business, which increased its revenue from just $27,000 when it launched near the end of 2018 to more than $14 million in 2021. But Nouhavandi says that as she has embraced distributing medication abortion, it’s been “disappointing” to see hesitancy from some investors. While her board and current investors are very supportive, she says, others she meets with—including people who say they support women’s health—are “skittish” about helping startups that work on abortion. And while Honeybee Health is based in a state that has moved to protect abortion rights, not all companies are in the same position. “We’re both supportive and outspoken regarding abortion rights,” Nouhavandi says. “But not all of our pharmacist colleagues have that level of support in their local environment.”
Preparing for the next shoe to drop
Despite the regulatory hurdles and the looming ruling on Roe, Nouhavandi feels energized. “I’ve never been more focused and excited as I have been in the last year,” she says. Which is good, because these days the business is crazier than ever. Since the Supreme Court leak, Honeybee has seen an 80% increase in demand for abortion pills, which now make up roughly 30% of the company’s orders. Honeybee has grown to nearly 75 employees. A self-described coffee fiend who was never very good at work-life balance, Nouhavandi now regularly works 14-hour days packed with six to 10 meetings—often with investors, regulatory advisors, and lawyers. When we spoke, she was working out of a coworking space in Las Vegas, where she’d gone to consult with a provider interested in using telehealth to prescribe abortion pills.
If Roe is overturned, not that much will change for Nouhavandi. Already 19 states effectively outlaw mailing abortion pills, and Honeybee only ships to states where doing so is legal. “We have to stay within the law to ensure that we can continue to doing this work. Because this is the first time pharmacy is doing this, the scrutiny on us is even more,” she says.
Some abortion telehealth companies and clinics work with patients who drive from states where abortion pills are restricted to a state with more permissive laws, in order to take their telehealth appointment and pick up pills. Others know that patients might give pills to a friend in a state with more restrictions once they secure the medication themselves. Honeybee can’t control what happens to the medication once it’s in patients’ hands, but Nouhavandi emphasizes that the company is determined to abide by local laws. “We understand that we’re part of a bigger fight,” she says. “And so we can’t just go rogue and push the boundaries, because it really jeopardizes the whole movement.”
As the potential end of Roe draws closer, Honeybee has put more information about medication abortion up on its website, and Nouhavandi says that she knows disseminating accurate information, and countering misinformation, will be one of the major fights ahead. Right now, she’s trying to help more providers get certified to prescribe mifepristone, while positioning her own company to grow if demand requires it. “If that volume increases significantly, we’re totally prepared,” she says.
Honeybee Health is not a panacea, Nouhavandi acknowledges. Every patient can’t use medication abortion, and Honeybee Health can only mail the pills to states in which abortion is legal. But by working to make the pills widely available, the company can help offload demand, allowing the shrinking number of clinics to handle the expected influx of people traveling to get procedural abortions across state lines.
And that, Nouhavandi says, will remain her focus even in a post-Roe America. The goal, she says, is to make it “as easy as possible for patients and providers alike to get access” to abortion—now and in the future.
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