Tracey Gehring, a 51-year-old mother from Greenbush, Mich., typically gets prescription medications delivered to her home about two to three days after she orders them. Recently, her anxiety medication took more than a week to arrive. "I've never had issues getting my prescriptions like this," she said.
In danger of running out, she was forced to ask her doctor for an emergency supply and persuaded a local pharmacy to fill it. Gehring's pharmacy benefits are administered by CVS Health, which she said requires her to fill any long-term medications though its mail order service or at a CVS pharmacy location. The nearest CVS store is an hour and a half from her home.
"I'm kind of in the sticks," she said. "I'm stuck with mail order."
Americans increasingly get their prescription drugs delivered to their homes, yet anecdotal accounts from patients—and some evidence from pharmacy benefit managers—about widespread U.S. Postal Service delays have exposed the pitfalls of prescription drug mail order services, which are often encouraged by insurers and their PBMs.
AllianceRx Walgreens Prime, a home delivery venture between Walgreens and PBM Prime Therapeutics, said prescriptions have taken longer to be delivered by the Postal Service since March, and the company is monitoring how those delays affect patients. In some cases, delivery has been significantly delayed by three or more days, a spokeswoman said.
AllianceRx attributed the delays to the COVID-19 pandemic, aircraft availability, significant network volume and the Postal‧Service elimination of overtime. It said it is evaluating soon-to-be-implemented postal rate increases and is looking at other mail delivery options if delays worsen. Alliance sends most prescriptions through the Postal Service, but also uses DHL E-Commerce to sort and enter shipments to the Postal Service, which helps speed up the process, it said.
Democratic chairs of the House Energy & Commerce committee said Monday they would investigate how U.S. Postal Service organizational and operational changes have affected the delivery of prescription drugs. Although Postmaster General Louis DeJoy said Tuesday that he would suspend certain changes to the Postal‧Service, the committee's investigation is going forward and oversight letters will be sent out in the coming days, a spokesman for the committee said. The Postal Service did not respond to requests for comment on the delays.
Pharmacist trade groups say mail order prescriptions are prone to delays or other problems that can make it hard for patients to stick to medication regimens. Benefit managers that are experiencing problems with the Postal‧Service insist that they are taking steps to ensure patients have timely access to their potentially life-saving drugs.
"Even before the slowdown there was some unpredictability in the shipment of medications," said B. Douglas Hoey, CEO of the National Community Pharmacists Association. "What the PBMs will say is that they auto-ship the medications so patients never have to go to the pharmacy or do without. But what they don't say is that sometimes those auto-shipments can get lost in the mail, or there's a slowdown like now, or (medications) are exposed to temperatures that in many cases are far outside the manufacturer's storage recommendations."
When patients experience mail order issues, the burden falls on local pharmacies that end up filling emergency supplies of medication. But those local pharmacies likely won't be reimbursed for that work, he said.
Scott Knoer, CEO of the American Pharmacists Association and former chief pharmacy officer at Cleveland Clinic, said medication compliance "is everything" when it comes to achieving good health outcomes, and major disruptions in mail delivery could significantly affect patients' health.
He noted that the trade group is most concerned about pharmacy benefit managers requiring members to use mail order without giving them a choice, which he said is becoming more common as health insurers and PBMs integrate. The practice is anti-competitive and putting local community pharmacies out of business, he said.
A CVS spokesman said the company gives clients the option to offer longer-term prescriptions for ongoing conditions, like diabetes, through mail order or at a CVS pharmacy. "This option has proven effective in creating member savings and keeping patients adherent, which in turn drives better health outcomes," he emailed.
There is some evidence that when prescriptions are delivered to the home, patients are more likely to take their medicines, compared with when patients fill prescriptions at retail pharmacies. Busy patients or those who lack transportation may also benefit from not having to visit a physical pharmacy to pick up medications.
"There are pros and cons. There's convenience—and it's especially apparent in the current pandemic—that you don't have to go in the store," said Jack Hoadley, a professor emeritus of health policy at Georgetown University.
Commercial insurers sometimes offer patients lower copays if they use mail order, and mail order has the potential to save healthcare costs by creating efficiencies in how the drugs are distributed, Hoadley said. On the other hand, patients may not get the counseling services that they would at the pharmacy counter, he said.
A spokesman for lobbying group America's Health Insurance Plans said PBMs do not require patients to use mail order; insurers work with plan sponsors "who may strongly incent mail-order." He said multiple studies have shown that mail delivery improves adherence, accuracy of prescription fills, and reduces costs and waste.
According to an August 2020 report by healthcare analytics firm IQVIA, 312.7 million prescriptions, or 4.9% of all prescriptions dispensed in 2019, were sent by mail. Mail delivery prescriptions accounted for $132.5 billion in spending before discounts or rebates, or a little more than a fourth of total U.S. spending on medicines in 2019.
Mail order prescriptions are generally handled by pharmacy benefit managers, which administer drug benefits for employers and health plans. In recent years, health insurers have merged with most large PBMs in multibillion-dollar deals. Pharmacy giant and PBM CVS bought health insurer Aetna in November 2019. A month later, Cigna Corp. bought PBM Express Scripts. UnitedHealth Group, the parent company of the nation's largest health insurer, also owns PBM OptumRx.
Mail delivery has become big business for insurer-owned PBMs as they look to keep costs within their own organizations. CVS reported $52.1 billion in mail order pharmacy revenues in 2019, up 10.8% over 2018. CEO Larry Merlo told analysts this month that prescription home delivery volume increased 500% in the second quarter of the year over the first quarter amid the COVID-19 pandemic.
But in recent months, some providers of prescription home delivery have had trouble getting medications to patients on time through the U.S. Postal Service.
Humana Pharmacy, part of Medicare Advantage insurer Humana, said increased small parcel shipping volumes are affecting all delivery carriers. It said it's working with Postal‧Service to ensure prescription home deliveries remain a priority.
"Humana is updating internal processes to reduce overall turnaround times, we continue to provide our customers with information about their shipment's status, and we're looking at additional ways to expedite shipments," a spokeswoman said in an email.
Alan Van Amber, senior vice president of provider services at Navitus Health Solutions, a PBM owned by hospital system SSM Health, said that while the company sends few prescriptions by Postal‧Service, it has seen one to two-day delays nationwide among a small percentage of those prescription deliveries. He noted a general slowdown in Postal‧Service deliveries since the beginning of the pandemic and throughout the protests. Navitus has also received a "slight uptick" in calls from members whose prescriptions were delayed or lost.
The company is advising members that could be affected to refill prescriptions earlier than normal. It allows patients to seek emergency prescriptions at local pharmacies when deliver problems arise. Amber said for certain medications, Navitus is also piloting a UPS program that skips U.S. Postal Service sorting facilities but hands the package over to the post office for the last mile.
The dominant PBMs, including Express Scripts, CVS and OptumRx, either said they haven't experienced any issues or declined to say whether they are dealing with mail delays. CVS said it is "closely monitoring the current situation" and working to ensure prescription deliveries are made on time.