7 Key Tips About PBM Mail Order Pharmacy

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Medically reviewed by, Russell Braun RPH

More and more people today are using mail order home delivery pharmacy.  Large retailers are all trying to compete for business and making buying from them more convenient than ever.  Pharmacies are no different.  Today there are many different varieties of mail order pharmacies.  Almost everyone who has insurance will also have a PBM mail order pharmacy.  The question is, should you use it? A PBM mail order pharmacy may be for you if:

  • You like to save money on your medications 
  • Avoiding venturing out to the drugstore sounds like a good option

1. What Is A PBM Anyway?

PBM stands for Pharmacy Benefits Manager.  Essentially, they are the company that is hired by your health plan to make sure your prescriptions can be filled when you go to the pharmacy.  Over the years they have grown into large companies that do a variety of other services as well.  One of those services is mail order pharmacy.  

Today PBMs do many functions for health plans and employers they represent.  They set up and manage formularies, handle prior authorizations, perform drug utilization review, determine patient copays and provide other member education.  

Mail order pharmacy, much like it sounds is where the PBM owns a pharmacy which mails prescriptions to your home.  These pharmacies are very large and have robots and automation that help them fill millions of prescriptions per year.  Your doctor simply sends the prescription to the mail order pharmacy and they can process it, bill your insurance and ship it to you. 
In addition to mail order pharmacies most large PBMs now own a specialty pharmacy also.  These specialty pharmacies fill high cost, high touch drugs that require extra pharmacist time and attention.

 2. The Good News About PBM Mail Order Pharmacy

PBMs and their mail order pharmacy can offer some useful services.  These services offer the following benefits: 

  • Convenience of home delivery.
  • Reduced errors in filling prescriptions.
  • Increase the amount of patients who actually use their prescriptions as the doctor prescribed. 
  • Typically provide a 3 month supply instead of just 1 month.
  • Normally a lower cost option.

3. The Bad News About PBM Mail Order Pharmacy

PBMs have grown very large and their ability to impact the whole pharmacy supply chain has grown.  This can be a positive but can also have negative consequences as well.  Some of the things that can impact you include:

  • Patient out of pocket copays could be higher than paying cash using a pharmacy discount drug card.
  • It can take up to 14 days to get a prescription filled.
  • You may not be able to use the drug your doctor had intended.
  • Certain medications may be damaged by exposure to extreme temperatures. 
  • Mail order pharmacies may not offer as many services and advice as your local pharmacy.    
  • Large 90 day supplies may wind up as wasted medication if you do not continue the therapy that long

In addition to the points above it is also important to know that PBMs can affect the prices you pay for drugs.  They negotiate prices with the drug manufacturer.  They then also negotiate a rebate with the manufacturer. The PBM will keep part of that rebate and pass the rest on to your health plan.  This allows your helath plan to keep your premiums lower, but doesn’t always help you out.

When a very expensive drug is being used, this becomes a big problem.  Pretend the drug costs $5,000 and becuase of the cost it is the highest copay for you which is $250. 

Without RebateWith Rebate
Drug List Price: $5,000Drug List Price: $5,000
Rebate: $0Rebate: $3,000
Health Plan Cost: $4,500Health Plan Cost: $1,500
Your Copay: $500Your Copay $500

As you can see the price your health plan paid came way down with the rebate. However, there was no savings that was passed on to you.  As you can see over time this adds up to quite a profit for a PBM. This is why PBMs have drawn a lot of scrutiny in recent years over drug prices.  

4. Do PBMs Own Pharmacies?

Almost all PBMs own a mail order pharmacy today.  Certainly all the major PBMs own a mail order and a specialty pharmacy. Both of which will mail prescriptions to you.   In addition, the very large PBM, CVS Health, also owns the largest chain of retail pharmacies in the U.S.

Using Their Size

Owning pharmacies helps the PBMs make more money on the services they provide. In many cases they will end up telling you what pharmacy you have to use, even if you don’t want to!

All the PBMs own pharmacies because they make more money filling scripts at their pharmacy. They can use large size and scale to bring down the cost of filling the scripts. This helps keep prices lower for your health plan and you get a lower copay for a larger amount in most cases. Here are a few ways PBM mail order pharmacies are different.

  1. They normally provide 90 day supplies of medications instead of 30 day supply.

2. After a certain number of fills your PBM may make you use mail order or pay higher prices.

3. The PBM sets your copay and how much the pharmacy is paid. Therefore, they can make your copay lower at mail and pay the pharmacy less if it is not one of their pharmacies.

5. Can Prescriptions Be Mailed?

It is legal to mail prescriptions in the United States. However, the pharmacy who mails them to you needs to be registered by the Drug Enforcement Agency (DEA). There are a few important things to keep in mind.

  1. Drugs that are controlled substances must be signed for, which means you would have to be home when these arrive.

2. Certain medications should not be subjected to extreme heat or cold. Ask your pharmacist if your medication should be shipped in a special temperature controlled container.

6. How Does Mail Order Pharmacy Work?

Mail order pharmacy today is more than just via your PBM. There are many options for getting drugs mailed to you. This can range from drugs people buy online to discount drug programs that now also offer this service even without insurance.

With Insurance

Your PBM mail order pharmacy is going to be a reputable licensed pharmacy. They will work with your doctor to get your prescription and fill it according to all the applicable laws. The medications will be Food and Drug Administration (FDA) approved and bought via reputable drug wholesalers.

The PBM mail order pharmacy will bill your insurance and provide you with a copay or coinsurance cost for the medication. Make sure to compare this cost with what it would cost to fill the script at your favorite local pharmacy. Today these pharmacies now offer similar prices, larger quantities and even delivery services.

Without Insurance

Online pharmacy

Some online pharmacies are legitimate and some are not. How can you tell if they are a good upstanding pharmacy that will mail your drugs at a good price? Well in order to ensure your getting real quality medications you need to look for the VIPPS accreditation.

VIPPS stands for Verified Internet Pharmacy Practice Site and they are the gold standard for online pharmacies to get accreditation. If you see the VIPPS seal on the website you can feel confident they have undergone inspections and will provide quality products.

Without VIPPS verification you could be buying from a site that is legitimate or one that is selling counterfeit drugs. You really have no way to know one from the other.

Drug discount card programs

Pharmacy discount card programs have stormed onto the scene in recent years. They offer discounts on medications without the need to use your insurance. Several different options exist and they have added a variety of features. Some of the most common drug discount programs are listed in the table below.

Blink HealthScriptSave WellRx

One of those new features include the option for mail order pharmacy. Again, you should ensure the pharmacy is VIPPS certified. Most offer delivery everywhere in the U.S. and prices may be cheaper than your insurance copay.

7. What Is The Best Mail Order Pharmacy?  

Mail order pharmacies are here to stay. More and more insurance companies will try to drive you toward using the services which can save them money overall. Recently, more new corporations such as Amazon are entering this market as well. That should prove beneficial to the consumers in the long run.

Here are the key things to consider to decide which mail order pharmacy is best for you.

While getting more medication might be less costly, not all prescriptions are good candidates for mail order. This is especially true for short term medications and those which need to be started right away. Talk to your doctor about mail order options to see if that would work best for you.  

Click here to get Dr. Jason Reed’s exclusive list of medication questions you MUST ask your doctor, for FREE!

Share Your Story

Have you tried a PBM or other mail order pharmacy? Also, please share how it worked for you. Chime in below with your comments and thoughts.

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