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US suppliers of abortion pills are scrambling to make backup plans as the Supreme Court decides whether to keep restrictions on key drug mifepristone.

Some personal clinics in New York, California and Kansas will offer mifepristone for now, but are preparing to offer an alternative abortion pill if a later decision essentially bans the drug. Several personal providers in Ohio could stop offering mifepristone altogether. A telemedicine provider plans to shut down for up to two weeks to adjust to new surgeries.

All of these efforts are aimed at maintaining access to the most common type of abortion in the US, even as a major litigation over mifepristone escalates.

Access to mifepristone is on the brink and could change quickly depending on what the country’s highest court rules as soon as next week. Judge Samuel Alito on Friday temporarily stayed lower court rulings restricting access to mifepristone to allow judges more time to consider the case.

But for now, telemedicine and in-person clinics could be forced to deal with significant restrictions on the drug, which could come into effect after Alito’s order expires at 11:59 p.m. ET Wednesday.

In this photo illustration, packs of mifepristone tablets are on display at a family planning clinic in Rockville, Maryland on April 13, 2023.

Anna Moneymaker | Getty Images

The U.S. 5th Circuit Court of Circuit late Wednesday froze part of Judge Matthew Kacsmaryk’s order suspending the Food and Drug Administration’s approval of mifepristone. But the court temporarily blocked delivery of the pill in the mail, ordered abortion patients to see doctors again, and reduced the length of time the pill was taken to seven weeks of pregnancy, down from the previous 10 weeks.

These restrictions will limit access to mifepristone even in states where abortion is legal. But the appeals court ruling does not restrict access to abortion pills in 17 states and Washington DC, which were the subject of a separate court decision issued last week, a federal judge in Washington said Thursday.

Some in-person abortion clinics in states where the procedure is legal told CNBC the surgeries will remain largely the same. But they also highlighted their contingency plans in case the court battle leads to stricter restrictions on the pill.

Trust Women, a clinic in Wichita, Kansas, will continue to offer mifepristone even after the restrictions go into effect, according to Zack Gingrich-Gaylord, the clinic’s communications director.

“We are not greatly affected by this ruling,” Gingrich-Gaylord told CNBC, citing the appeals court’s decision. “But we are still prepared to pivot if there are further restrictions. We have the alternate protocol ready.”

The clinic is poised to offer misoprostol as a standalone treatment if a later decision overrules the FDA’s approval of mifepristone, Gingrich-Gaylord said. The drug is typically used in the US in combination with mifepristone in abortion patients

Misoprostol alone is recommended worldwide as a safe and effective treatment for women wishing to terminate their pregnancy. The appeals court’s decision does not affect access to the drug.

Choices Women’s Medical Center in Queens, New York, and the University of California San Francisco Center for Pregnancy Options will also continue to offer mifepristone and have misoprostol-only therapy as a backup plan, hospital officials said.

But some in-person abortion clinics in Ohio may stop dispensing mifepristone altogether when those restrictions go into effect, according to Jessie Hill, an attorney representing several independent providers in the state.

Hill, who is also a law professor at Case Western Reserve University, said Ohio law requires physicians to follow federal labeling guidelines when prescribing mifepristone. She noted that the law means clinics can’t prescribe a drug in a way that hasn’t been approved by the federal government, known as “off-label” prescribing.

Other clinics in states where abortion is legal can prescribe mifepristone outside of the first seven weeks of pregnancy, Hill said. She said this allows clinics to effectively circumvent a limitation in the appeals court order in a way that Ohio providers cannot.

“The regulation makes it particularly impractical for Ohio clinics to prescribe mifepristone, so they probably won’t do it.” We could be the only state in this strange situation,” Hill said.

She noted that some clinics may begin offering the misoprostol-only regimen once the restrictions take effect because it’s “actually a better option for most at this point”.

US-based telemedicine clinics may have to make more sudden changes than in-person providers due to mifepristone mail delivery restrictions.

Abortion Telemedicine will only offer misoprostol in states that allow it when restrictions go into effect Wednesday, according to provider founder Jayaram Brindala. The clinic looks after patients throughout the first trimester, i.e. the 13th week of pregnancy.

Just The Pill is also prepared to offer patients “the safe and effective pure misoprostol therapy when needed,” said Dr. Julie Amaon, the company’s medical director. Just The Pill supplies abortion drugs in Wyoming, Montana, Colorado and Minnesota.

Wisp, a company that offers telemedicine medical abortions in nine states, will also transition to offering only misoprostol when those restrictions are implemented, according to Monica Cepak, the company’s chief marketing officer.

But that change would require the company to close for up to two weeks starting Wednesday, she noted.

“Right now we are in our status quo mode and will remain so until we hear further developments,” Cepak said.

She emphasized the critical role of telemedicine in abortion care in the US, noting that the increasing demand for in-person services is making it difficult for patients to schedule appointments.

“It can sometimes take 20 to 40 days. That’s too long to wait for most people,” she said. “Telemedicine fills that gap.”

US Supreme Court Justice Samuel Alito on Friday temporarily blocked rulings by lower courts that imposed tighter restrictions on the abortion pill mifepristone.

US Judge Matthew Kacsmaryk of the US Northern District of Texas last week suspended the Food and Drug Administration’s approval of mifepristone.

The US 5th Circuit Court of Appeals blocked that part of Kacsmaryk’s order and allowed the FDA approval to stand. However, the Court of Appeals temporarily reinstated stricter restrictions on the use and distribution of mifepristone, which would make it more difficult for women to access the drug.

Alito blocked those decisions that limited access to mifepristone until 11:59 p.m. ET Wednesday. The Alliance Defending Freedom and Alliance for Hippocratic Medicine, the anti-abortion groups that have sued the FDA, have until noon Tuesday ET to submit their response.

The Supreme Court, which has a 6-3 Conservative majority, will next decide whether to keep mifepristone more widely available while the Biden administration’s appeal expires. But the court could also vote to reinstate the limits once the appeal is decided.

The final outcome of the national litigation over mifepristone could severely limit access to the drug, even in states where abortion remains legal. Mifepristone, used in combination with another drug called misoprostol, is the most common method of abortion in the United States, accounting for about half of all abortions.

US Attorney General Elizabeth Prelogar said the lawsuit against the FDA was “disturbing on every level.” She said the lower court rulings are the first time judges have overturned the terms of an FDA drug approval because of a disagreement over the agency’s ruling on safety.

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“If enacted, the lower court orders would upend the regulatory system for mifepristone, with far-reaching implications for the pharmaceutical industry, women who need access to the drug, and the FDA’s ability to implement its statutory authority ‘ said Prelogar.

5th Circuit Justices Kurt Engelhardt and Andrew Oldham, appointed by former President Donald Trump, have reversed virtually all regulatory action the FDA has taken against mifepristone over the past 20 years.

Court of Appeal judges blocked mail delivery of mifepristone, reinstated doctor visits as a condition of receiving the drug, and shortened the time frame that women can take it up to the seventh week of pregnancy. They also blocked approval of GenBioPro’s generic form of mifepristone in 2019.

The legal landscape surrounding mifepristone has become chaotic and uncertain over the past week. US Judge Thomas Rice in the Eastern District of Washington issued a competing order that the FDA maintains access to mifepristone in 17 states and Washington DC

The US government told the Supreme Court that complying with the 5th Circuit’s restrictions would violate the Washington State District Court’s order.

The Justice Department said the Texas and Circuit Court of Appeals rulings would mislabel all doses of mifepristone on the market because their labeling would not align with the 2000 FDA approval. The government said it would take months to realign labeling, which would deny women access to drugs approved by the FDA as safe and effective alternatives to surgical abortion.

Danco Laboratories, the distributor of the abortion pill, said it would not be able to commercialize mifepristone until the FDA took a series of actions to implement the lower court’s rulings.

“The direct consequence of the Fifth Circuit’s decision is that the FDA must obtain a comprehensive set of approvals in order to implement the Fifth Circuit’s retraction. Without these approvals, Danco cannot legally market and distribute mifepristone,” wrote Jessica Ellsworth, the company’s attorney.

The Florida House of Representatives passed legislation on Thursday that would ban most abortions after six weeks when many people are unaware they are pregnant.

The bill passed by a vote of 70 to 40, largely along party lines. The measure now goes to Florida Gov. Ron DeSantis, who is expected to sign it into law.

Just last month, he reiterated his support for tougher abortion restrictions, saying, “We welcome the pro-life legislation.”

The bill would only go into effect if the state’s existing 15-week ban is upheld in an ongoing litigation in the state Supreme Court. The Republican governor signed this ban last February, which includes no exceptions for rape, incest or human trafficking.

The new legislation would make performing an abortion after the six-week period a third-degree crime, punishable by up to five years in prison.

However, there are exceptions in the case of rape and incest up to the 15th week of pregnancy after medical determination. In these cases, a pregnant person would have to provide documents such as a medical record, a restraining order, or a police report to prove they are a victim.

DeSantis called those and rape and incest provisions “reasonable” last month.

The bill also allows abortions in serious medical emergencies. However, only on the condition that two doctors certify in writing that an abortion is necessary to save the life of a pregnant person or to avoid a serious risk of significant and “irreversible physical impairment” of a bodily function. A single doctor can make this call when a second one is unavailable for the consultation.

Abortion is also allowed up to the third trimester if a fetus has a fatal abnormality, but two doctors must confirm this in writing.

A six-week limit would align the state more closely with the abortion restrictions of other GOP-controlled states. It would effectively end Florida’s reputation as a safe haven for people from other Southern states seeking abortions.

The move could also give DeSantis a potential political boost among Republican voters ahead of a potential presidential nomination in 2024.

Before the vote, Republican lawmakers reiterated longstanding conservative views on abortion.

Rep. Jenna Persons-Mulicka said the bill would save lives, noting the more than 82,000 abortions recorded in Florida last year.

“Today we stand for life, we stand for mothers and we stand for families in Florida,” Persons-Mulicka said. “We can transform the culture of abortion into a culture of life.”

State Democrats have criticized the bill since it was introduced early last month. The Florida Senate’s vote to pass the law last week sparked demonstrations outside the state Capitol in Tallahassee that led to the arrests of two of the state’s Democratic lawmakers.

Other Democratic officials slammed the bill on the floor of the House of Representatives before voting.

“Abortion is health care,” Rep. Kelly Skidmore said three times in a row. “This law denies it to millions of Florida residents. This is a dangerous law. We will never agree on that.”

“What you’re doing is telling every Floridian that they need to live how you want them to live, not how they want to live,” she continued. “Stay out of my business.”

Rep. Robin Bartleman similarly said, “The right to bodily autonomy is an innate right.”

“My body is mine. We don’t want unclear laws and muddy waters,” Bartleman said.

A recent poll suggests that the six-week abortion ban is not popular with Florida residents. About 75% of more than 1,400 people opposed the ban, according to a University of North Florida poll released in March.

The bill comes as a chaotic legal battle over the abortion pill mifepristone heats up. The US 5th Circuit Court of Appeals overnight froze part of a Texas judge’s order that would have suspended the Food and Drug Administration’s approval of mifepristone.

The Biden administration will ask the Supreme Court to intervene, Attorney General Merrick Garland announced Thursday.

The Florida action also marks a broader shift in abortion litigation in the United States after the Supreme Court ruled in June’s 50-year-old Roe v. Wade had picked up. After this decision, the right to abortion was largely left to individual states.

Some states have rushed to ban the procedure outright, while others have gradually introduced new restrictions. Most abortions are now banned in more than a dozen states, including Idaho, Texas, Tennessee, Wisconsin, West Virginia and Oklahoma.