THE BASICS
Below you'll find some basic information about what mail order pharmacies are, how they work, why we use them, and what my thoughts are about them.
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FAQs
WHAT IS A
MAIL ORDER PHARMACY?
Mail order pharmacies are pharmacies that are located in warehouse or suite spaces across the United States. Instead of having patients pick up their medications on site or delivering them locally, these pharmacies ship prescriptions to patients through the mail via USPS or carriers like FedEx and DHL.
WHO OWNS & OPERATES MAIL ORDER PHARMACIES?
The majority of these pharmacies are owned and operated by Pharmacy Benefit Managers. However, there are certain retail companies like Costco and Sam's Club that have mail order pharmacies (which are separate from the pharmacies that operate locally in their stores). Local pharmacies like chains and independents may also offer the shipping of prescriptions, but this doesn't make them a traditional "mail order pharmacy."
WHAT IS A PBM?
Pharmacy Benefit Managers (PBMs) are middlemen that exist in the pharmacy world between pharmacies that fill prescriptions and payers that, well, pay for them (which include private insurance companies, large employers (think 3M and Boeing) who are self-insured, and the federal and state governments).
WHAT IS PBM ABUSE?
PBMs are known for all sorts of abusive practices (grouped under the umbrella term of "PBM abuse") and are currently in the hot seat for the many ways in which they harm our nation's healthcare system and its patients, providers, and even payers (think: the federal and state governments that pay for patients' care using taxpayer dollars). Click here to read a recently published article from the New York Times about their extensive investigation into PBMs.
WHAT ARE MAIL ORDER PHARMACIES LIKE?
In short, not very much fun to work with. As you'll learn all about on this site, mail order pharmacies are not famous for providing high-quality pharmacy care; rather, their confusing policies and workflow, lack of transparency, poor communication, and refusal to do certain things that local retail pharmacies are expected to do (e.g., call another pharmacy for a prescription transfer) make them, in many cases, an inefficient and unsafe alternative to high-quality local pharmacy care, such as that provided by many independent pharmacies. These inadequacies alongside their policy that medication that has been shipped is non-returnable and non-refundable make it easy for patients to build an expensive stockpile of medication that they don't need and/or can't afford. Additionally, they regularly depend on the local pharmacies that they're helping to put out of business to pick up the slack in emergency situations when a patient is going to run out of medication before they receive their mail order shipment (in my experience, often due to delays that are their fault, not the patient's).
After nearly two years of getting to know mail order pharmacies, it's become clear to me what the crux of their problem is: they put all of the burden of ensuring safe, efficient, and reliable pharmacy care on you—the patient—rather than the other way around.
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Click here to read the Costs of Mail Order Rx report from the National Community Pharmacists Association (NCPA).
IF THEY'RE SO BAD,
WHY USE THEM?
Despite their inadequacies, there are certain situations in which it makes sense to fill prescriptions through a mail order pharmacy.
Admittedly, they can be the best fit for patients who are unable to transport themselves to or get delivery from a local pharmacy.
They might also be the most affordable option for filling your prescriptions using insurance, depending on your drug coverage. Because PBMs want patients to be using their own pharmacies (see below), for some time there's been an industry standard of traditional mail order pharmacies being patients' cheapest option so that they're incentivized to use them; sometimes, patients are even forced to use the mail order pharmacy owned by their plan's PBM, which we call "patient steering." These savings might be especially helpful for patients living on a fixed income, like retirees, or those who already have high health costs (notably, new evidence (see this article or this report) suggests that, despite being cheaper for patients, mail order pharmacy is often costing employers and other payers through whom we get insurance more compared to retail pharmacy).
Lastly, they can serve as an alternative way to fill prescriptions if your local pharmacy is currently losing money doing so (most common with expensive brand-name drugs and a prime example of PBM abuse).
THE IDEAL
MAIL ORDER PATIENT
Based on my own experience, mail order pharmacies are best used by patients who are technologically savvy, since the most efficient way to work with them is through their website or smartphone app. Additionally, they're not a great fit for filling emergency medications (e.g., antibiotics for an acute infection) or last-minute refills of a maintenance medication, since it takes longer to get prescriptions through the mail than it is to fill them at a local pharmacy.
In my experience, it would be difficult to near impossible for most Medicare-aged patients to use a mail order pharmacy on their own, and would likely require a support person to manage their mail order needs for them in order to do so.
WHAT IS A
SPECIALTY PHARMACY?
A specialty pharmacy is subtype of mail order pharmacy that—you guessed it—fills "specialty" medications only. Specialty drugs are high-cost prescription medications used to treat complex chronic conditions (think: cancer, multiple sclerosis, or Huntington's disease). They sometimes require special handling and administration (like an injection or infusion), and patients using them may need careful oversight from a healthcare provider. However, classifying a medication as "specialty" is not FDA-, but PBM-derived, and is simply another way of isolating these medications (and their pricing) from others. In reality, they're mostly medications that would be perfectly appropriate to fill at a local retail pharmacy, and labeling them as "specialty" forces patients to fill them at certain pharmacies (i.e., PBM-owned) and increases the amount of money patients can be charged for them (and PBMs can make from them).
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Most traditional mail order pharmacies (those owned by a PBM, like CVS Caremark, Express Scripts, and OptumRx) have their own specialty pharmacy that coexists alongside their mail order pharmacy (patients may even use the same login credentials for both). Currently, Costco offers specialty medication services, but Sam's Club does not (as far as I can tell).
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An interesting thing to know about specialty pharmacies that I've learned through my own experiences managing patients' mail order needs is that they appear to provide better quality patient care (though still greatly lacking, in my opinion). For example, they're more communicative with patients, reach out automatically to check in about refills, and altogether seem to make it easier to speak with an actual human being instead of a robot when you give them a call. Their argument for offering this heightened level of service compared to their run-of-the-mill mail order pharmacies is that it's warranted for patients taking these types of medications (Optum Specialty Pharmacy states on their website that they offer "more personalized patient care, communication and resources for special conditions"). Yet, as a nurse, I can say without a doubt that this is a minimum level of service that should be available to ALL mail order patients, whether or not they take specialty medications (and, as someone who literally grew up in an independent pharmacy, pales in comparison to the quality of care provided by us and fellow indies).
ALTERNATIVES TO
MAIL ORDER PHARMACY
Based on my experience, if you're looking to transfer your prescription from your local independent pharmacy but aren't interested in using mail order, your options would include a local chain pharmacy (e.g., CVS, Rite Aid, Walgreens) or a local delivery-only pharmacy (Capsule is the only one that I'm personally aware of and is available in mutliple states).
The primary pro to using one of these options instead of a traditional mail order pharmacy is the safety net and possibly quicker service offered by filling things locally. Additionally, they're better able fill certain prescriptions that mail order services can't (e.g., emergency antibiotics).
There may be additional pharmacy options in your area, so check around to see what's available!
MY TAKE on MAIL ORDER
As a person with nearly two years of experience managing patients' mail order needs under my belt, I have no qualms saying:
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Traditional mail order pharmacies, as they operate now, are NOT a safe, efficient, and reliable alternative to local pharmacy care.
"Traditional" mail order pharmacies are those owned and operated by PBMs; while Costco's mail order service has (and, likely, Sam's Club and some other competitors would) proven to me that they're providing a far higher quality of pharmacy care, in my opinion, their website still lacks a level of user-friendliness that I think should be required for mail order pharmacies' online portals, and all mail order pharmacies face the limitation of not being appropriate for filling certain prescriptions, such as emergency antibiotics. Additionally, new evidence (see this article or this report) suggests that mail order prescription costs, while most often cheaper for patients, are grossly inflated for employers and other payers through whom we get insurance—a great example of what we call spread pricing, where the PBM in the middle underpays the pharmacy and overcharges the payer, keeping the difference for themselves. For this reason,
the idea of a world in which those of us living in the US only have the choice between a handful of overworked local chain pharmacies and mail order pharmacies, admittedly, scares me.
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Theoretically, I think the mail order model is valuable for certain patients (like those who are homebound and for whom the shipping of medications works well). However, like any pharmacy, this would require it be done with efficiency, transparency, and care (which I can promise you, these days, it's mostly not). In my opinion, if mail order pharmacies are going to remain a viable option for providing pharmacy care in the US, their current way of doing business must be reevaluated, and they, like the PBMs that run (most of) them, need to be held accountable for the harm they've already done to patients. And while there is (thankfully) increasing discussion nationally about addressing PBM abuse, I've unfortunately seen close to nothing regarding the abusive conduct of mail order pharmacies specifically.
That said, I've successfully used them to fill certain prescriptions for my patients and have counseled dozens of others on how to do it themselves, and it's doable. The reality is that they're a necessary evil that many of us, whether we like it or not, will need to use at some point, but the better prepared we are to use them, the better prepared we'll be to advocate for ourselves when we do. And, because these pharmacies will happily fill prescriptions that independent pharmacies are almost guaranteed to lose money filling due to chronic under-reimbursement from PBMs, my work has proven that they can also serve as a way for patients to help keep their local indie pharmacy alive while our nation awaits legislative reform of the insurance industry and accountability of PBM abuse from government entities (think: play the short game to win the long game... even if we're playing it with our enemy). In the meantime, I hope the information you find here will help make your experience working with them as smooth and safe as possible.