Are they really better?
We all love convenience! Anything to make our lives easier seems like a good thing, right? One would think that having prescription medications delivered to your door is the best thing ever. You avoid having to get into your car, drive to the pharmacy, wait in line (there’s always a line), and finally drive home. However, there are drawbacks to prescription delivery. What are they? How do you decide which method is better for you?
When you have a prescription delivered in the mail, you don’t have to pick it up from a pharmacy. Given the ease of the process, it’s not surprising many Americans are turning to this method. According to an analysis conducted in 2020, the number of American adults receiving prescriptions via mail order in 2018 was almost 26 million. In 1996, the number was close to 13.5 million. A report from IQVIA’s Institute for Human Data Science found that, as of 2016, prescriptions fulfilled by mail represented close to 25% of total US spending on pharmaceuticals (before rebates and discounts). When quarantines related to the COVID-19 pandemic started in 2020, home delivery of medications jumped by 20% in March and April. Since the need to isolate continues, experts speculate that more people may choose to get their prescriptions via home delivery now more than ever before.
The ability to provide prescriptions to patients by mail has been available for more than a century. When it started, it was only for those who lived in remote areas. In 1946, the Veterans Administration (VA) began offering the service to eligible veterans. Today, the VA accounts for nearly one-third of the mail-order prescriptions, with more than 330,000 veterans receiving medications in the mail every workday. Shortly after the VA implemented their program, the American Association of Retired Persons and the National Retired Teachers Association formed a mail-order pharmacy that was not-for-profit and served only their members. By 1963, for-profit entities began to promote mail order pharmacy services to corporate, government, and union employers. In the 1980s, the industry saw rapid growth, with revenues soaring from $100 million to $1.5 billion. Thanks to the internet, the trend continued throughout the 1990s.
Mail-order pharmacies usually operate through an insurer’s pharmacy benefit manager (PBM), the middlemen and cost drivers of the prescription drug supply chain. CVS Caremark, Express Scripts, and OptumRx are the three largest. Combined, they have nearly 80% of the US prescription benefits market. In 2019, it’s estimated that they took in $113 billion, collectively. PBMs buy medications in large quantities directly from the drug companies, so they’re able to offer them at discounted rates. As a result of the cost savings, some insurance providers require their participants to use a mail-order pharmacy to treat chronic conditions (maintenance medication). Many individuals find if they don’t use the mail-order pharmacy promoted by their insurance plan, they have to pay excessive amounts for the same drugs. In some cases, people are informed that their health insurance won’t cover their prescription unless they’re filled through the mail-order pharmacy. Over the past few years, several state legislatures have passed laws trying to prevent PBMs from forcing people to get their prescriptions by mail. Unfortunately, many of those laws have loopholes. Also, most state laws about insurance don’t apply to the employer-funded plans common among large companies.
There are benefits to using mail-order pharmacies. For certain generic medications for chronic conditions, many mail-order pharmacies offer a 90-day supply for a small, or no, co-payment, including free shipping, in some cases. This is different than traditional pharmacies that typically offer a 30-day supply at a higher rate. Besides the cost savings, the nice thing about a 90-day supply is that your prescription needs to be filled less often. Another benefit is the ability to sign up for refill reminders, so you’ll know when it’s time to reorder your medications. This is done through email or an automated telephone call. Some companies even have the option to synchronize multiple refills at once. You can also check the status of your order online or by phone. It’s easy to view your prescription history online and access consumer education information about your medications. If you have a question, you can access 24/7 service through the company’s website or telephone. This is especially helpful if you have questions outside of typical business hours because you can speak directly with a pharmacist to ease your concerns. When it comes to safety, every prescription is reviewed by a pharmacist before shipping. Whether it’s a physical store or mail order one, it’s the law that a licensed pharmacist must physically check every prescription before it goes to the recipient. OptumRx handles more than 1.3 billion prescriptions annually and ensures this occurs for every one of them. All medications are sorted and scanned using high-resolution and high-speed scanners. The information is verified by pharmacists and goes through up to 16 quality checks. Suppose there is a mismatch in the process. In that case, the medication is diverted to an employee for a recount and visual inspection to ensure the drug matches the medication’s shape, markings, and color.
To use a mail-order service, a healthcare professional sends the prescription to them, usually electronically. Your prescription is run through insurance, filled by the pharmacy, and the medication is mailed directly to you. If you can use mail-order or a traditional pharmacy, it’s essential to look at copays because often there’s a difference. To find out your coverage options, log in to your health insurance provider’s website. This is important to limit your out-of-pocket expenses. It’s imperative to note that most Medicare Part D drug plans offer mail-order prescriptions. Just be aware that your out-of-pocket costs change when you reach the coverage gap, depending on how your plan is designed. You can continue to purchase a 90-day supply through your Part D plan after you reach the coverage gap, but you might be able to save money by comparison shopping. To help with this, look into AARP’s discount prescription medication program for its members, which can be used at over 66,000 pharmacies. If you don’t have health insurance with drug coverage, there are mail order options to help you get discounted prescription drugs. Some companies, like RxOutreach, Xubex, and GoodRx, offer mail order pharmacy services you can take advantage of if you don’t have health insurance. One way to reduce cost is asking your doctor if you can use a generic medication instead of a brand one. Also, check if the drug is available through low-cost programs available at Walmart, Target, or supermarket chains because these may be the least expensive option. To compete, many traditional pharmacies now offer 90-day supplies of prescriptions with low copays. In addition, large chains, such as Walgreens and Wal-Mart, are now offering services that allow you to order medications through the mail with the option to pick them up at a local pharmacy location or to have them mailed to your home. Walgreens issued a statement recently that it’s working with FedEx to offer next-day medication delivery. The competition in the mail order industry is increasing since Amazon bought the online pharmacy PillPack.
There are specific scenarios in which using a mail-order pharmacy wouldn’t make sense. If you need a prescription quickly, such as an antibiotic to treat an infection, then you would want to go to your local pharmacy. Another reason is if your prescription is for a controlled substance because there are restrictions on what can be shipped by mail. If you take a medicine that needs to be compounded, or made specifically for you, most mail-order pharmacies don’t make these. If you’re starting a new medication/regimen or need additional medical supplies, it’s better to stop at your local pharmacy. There are also downsides to mail-order pharmacies. Patients are routinely denied coverage or find their medications significantly delayed. Insurers and PBMs claim that the delays are rare. An added issue is that, as with any package, drugs could be lost, stolen, or damaged in the mail. A medication needs a signature to be delivered in some cases, so it won’t be left if there’s no one home. It’s significant to note that this service usually costs extra. Some people say they take off work to ensure temperature-sensitive drugs aren’t left sitting outside all day or sent back to a warehouse if they aren’t home to sign for it. The issue with medications being left on doorsteps presents a different problem. When you look at your prescription bottles, most say “Store at room temperature” or “Keep refrigerated.” What happens they’re transported by mail? Often, standard, room-temperature medications are typically sent in bubble mailers without any temperature monitors. This could lead to them being potentially damaged by exposure to extreme heat or cold. While some room-temperature drugs are approved to spend up to 24 hours in temperatures from as low as the upper 50s to as high as 104 degrees, scientists don’t know how most medications respond to more extreme temperatures. When it comes to medicine that needs to be cold, like insulin and GLP-1 agonists, the companies are supposed to use special refrigerated packaging. Sometimes, these don’t work correctly, so experts recommend that you unpack these drugs as soon as possible and make sure they’ve stayed cold. Freezing temperatures or a poorly placed ice pack can freeze a drug, causing it to become ineffective. The problem is if the drug has thawed by the time it reaches the patient, there may be no visible trace of potential harm. It’s important to note that proving a drug became ineffective or made someone sicker because it was exposed to extreme temperatures is almost impossible. Typically, the medication is likely to have been consumed or thrown away by the time this is considered, preventing it from ever being tested.
NBC News investigated the temperatures of packages by sending five temperature logging devices across the country via UPS, FedEx, and the Postal Service. The interior of a standard bubble mailer reached above 104°F in four of five packages. The US Pharmacopeia (USP), a nonpartisan group that sets national standards for drug handling, advises this is the hottest temperature room temperature medicines can be exposed to. In addition, three of the packages went below freezing for hours during transit. All three delivery organizations said they offer a range of delivery and signature options, but it’s up to the shipper to choose the right option for each product and use packaging that sufficiently protects them from extreme temperature exposure or damage. Per industry guidelines, pharmacies should package and ship medications according to their recommended temperature range. Indicators that can tell what the internal temperature of a package is cost as little as a dollar per parcel. Despite this, they usually aren’t included. This means mail order pharmacy customers have no way of knowing whether their medicine has gone too far outside of the correct range for too long. Local pharmacists say it’s not uncommon for long-time customers to ask if it’s safe to take medication left on a doorstep for hours or for emergency refills because their mail-order one might be spoiled.
Concerns over the temperature of mailed medications are starting to catch the attention of federal law enforcement. For example, in 2016, the Justice Department demanded CVS Caremark provide documents as part of an investigation into its “handling of certain temperature-sensitive pharmaceuticals.” Per sources familiar with the investigation, the examiners are focused on whether CVS knowingly used ineffective methods to insulate shipments of refrigerated medications to customers as far back as 2010. The investigation was still active as recently as 2019. The Pharmaceutical Care Management Association, a national trade industry group for PBMs, issued a statement in response to concerns about the temperature of mail-order drugs: “Mail-service pharmacies adhere to all Food and Drug Administration rules, ship those prescription medications that may be adversely affected by extreme heat in refrigerated packaging, and notify patients to make sure those packages have been delivered properly.” They further detailed that its members use proprietary software to monitor the weather and map the potential temperatures a sensitive package may be exposed to on its delivery route. They insist mail-order pharmacies are safe and reliable.
Many experts feel that insurers and their PBMs should reconsider the incentives they use to encourage people to use mail-order pharmacies until the issues related to temperature are solved. The problem is the industry occupies a gray area of regulation and enforcement. Many large mail-order pharmacies voluntarily meet independent accreditation standards every three years that evaluate their standards for safe medication delivery. When it comes to government oversight of the companies, it falls to the state boards of pharmacy of all 50 states. Most don’t have specific rules for how pharmacies should ship customers’ medication. Only six states have guidelines focused on proper packaging or temperature monitoring for home delivery. Two states, Georgia and Utah, have inspection forms to see if those decrees are being followed. This means the majority of states say it’s up to the pharmacy to ensure safe shipping. The other issue is drugs are often shipped from warehouses outside the state, and most states only inspect facilities physically within their borders. According to one official, it’s just the nature of the industry right now. Technically, the pharmacies aren’t in violation of a law, even though what they’re doing might be unethical and unfair. Local pharmacists say this is a double standard because temperature oversight from pharmacy boards is strict regarding how they store medication, but those same rules aren’t applied to mail-order pharmacies concerning shipping. The good news is industry practices are changing. Recently, USP began inspecting pharmacies’ shipping methods for room temperature medication, which it previously only did for refrigerated ones. They’ve also updated their guidance on specific ways pharmacies can limit the risk of temperature exposure during transit. While these have gone into effect, enforcement still falls to state pharmacy boards.
There are several things to consider before using a mail-order pharmacy. Since it can take up a couple of weeks to receive your medications through the mail, you may want to ask your doctor for two prescriptions: one to be filled right away at your local pharmacy and one for your mail-order supply. When getting a prescription from your prescriber, ask for a printed copy of it. This will allow you to compare the drug label to the prescription to ensure that the medication name, dosage, and instructions are the same. Sometimes a prescription will be for a brand name, but the pharmacy will use a generic equivalent. If you don’t recognize the drug name, call your prescriber to make sure it’s okay. Also, look on the drug label for a description of the medication’s appearance, which should include the color of the pills and any writing that should be on them. Also, make sure the label has your name on it. If anything doesn’t look right, call the pharmacy service and your doctor before taking the medication. If you get some of your medicines via mail order and others at a walk-in pharmacy, make sure each one knows about all of the medicines you’re taking and update them regularly about any changes. This is vital so your pharmacist can alert you to potentially dangerous drug interactions. To avoid delays in getting medications, sign up for automatic refills, or set a reminder to order your medicines at least two weeks before you’ll run out. If you wait to order a refill, you might need to pay for overnight or one-day shipping to get it in time, which can be expensive. It’s also a good idea to set up an alert that notifies you before an automatic prescription is refilled. This is important to make sure if the prescription changes in any way, you have time to get the pharmacy an updated script. If your medications are damaged or lost, call your pharmacy’s 1-800 number immediately for a replacement.
Another thing to be aware of is that mail-order pharmacies and online pharmacies aren’t the same, even though both will ship medicines directly to your home. Mail-order pharmacies operate through your insurance’s health plan. Online pharmacies tend to work more like a traditional pharmacy, except they’re electronic. They may or may not accept your insurance. One concern is that online pharmacies can operate from anywhere in the world, which means they aren’t subjected to US laws that regulate the medicines they sell. While there are plenty of legit online pharmacies, but there are also fraudulent ones. Sometimes, the medications they sell are counterfeit. Before using an online pharmacy, verify that it’s licensed through your state’s board of pharmacy. You can also check with the National Association of Boards of Pharmacy (NABP), which provides a list of Verified Internet Pharmacy Practice Sites. To be included on the list, an online pharmacy must comply with the NABP’s privacy, security, and quality assurance criteria. The NABP also provides a list of sites it recommends avoiding. Mail-order pharmacies certified as a Verified Internet Pharmacy Practice Site (VIPPS) will have the official logo on their site. To maintain their certification, they must be reviewed every three years. There are fewer than 50 pharmacies in the US that have this accreditation. It’s essential to keep in mind that dishonest pharmacies will say you don’t need a prescription for medicine, controlled substances, or narcotics to be able to get them. This is a red flag because it’s illegal.
Mail order can be a good option for some, but it can also be a hassle. For the time being, pharmacy experts still question the safety of mail-order drugs, chiefly because few regulations are in place/enforced, and the effects of temperature extremes haven’t been studied in detail. To correct this problem, we need reforms that create real accountability for PBMs and insurance companies. In the meantime, there should be flexibility in the requirements of using only mail-order pharmacies for certain medications. People should be able to have confidence that the medicine they receive is safe and effective!