Millions of Americans receive their prescription drugs by mail, some not by choice. According to the Kaiser Family Foundation’s (KFF) 2019 Employer Health Benefits Survey, 4 percent of healthcare plans only cover prescriptions ordered through online pharmacies. Further, enrollees in 58 percent of plans are incentivized financially to order their prescriptions by mail. But ordering temperature-sensitive drugs by mail may increase the risk of exposure to less-than-ideal temperatures, potentially rendering them unsafe or less effective.
Getting prescription drugs by mail
As more healthcare plans have begun requiring or making it more cost-effective for consumers to use online pharmacies, many Americans have jumped on the mail-order bandwagon. The practice has become especially popular in rural areas, where residents live a greater distance from brick-and-mortar pharmacies. And in 2020, a desire to avoid potential exposure to the coronavirus led more people to order drugs by mail, according to KFF, which reported a 21 percent spike in mail-order prescriptions in late March versus the previous year.
Temperature-sensitive medications
Certain common medications, such as insulin, are highly temperature-sensitive and must be kept in a controlled environment throughout the supply chain and delivery process. Industry guidelines require that pharmacies package and ship medications in accordance with their recommended temperature range, as higher or lower temperatures could potentially make medication unsafe or ineffective.
Express Scripts Pharmacy, a major provider of online pharmacy services, shipped 4.5 million coolers of temperature-sensitive medications in 2019 and was on track to deliver 5 million in 2020, according to the company’s website. Using proprietary software, Express Scripts states on its website that it “takes into account the acceptable temperature range for each medication, as well as all the forecasted weather patterns the medication will pass through on its journey from our pharmacy to the patient’s hands.” Where applicable, the company affirms that it packages medications in temperature-protective coolers with gel packs to ensure that the “medications stay within a safe temperature range – even if the package is sitting outside for several hours after delivery.” Additionally, customers receive notifications when the package has been delivered to limit extended exposure to the elements on the customer’s doorstep, according to Express Scripts’ website.
While there are guidelines in place, many mail-order pharmacy customers worry that their medicine may not be handled at optimal temperatures at some point along the way. The pandemic has significantly increased demand for home delivery of all kinds of products, which has coincided with financial struggles for the U.S. Postal Service and resulted in late deliveries of prescription drugs. According to an Ipsos poll in August, one in four people who had ordered medications through the mail in the prior week had experienced a delay or non-delivery. Delays in delivery increase the likelihood that medication will be exposed to temperatures outside the ideal range.
NBC News investigates mail-order complaints
For a report that aired in December, NBC News investigated the complaints of more than 65 mail-order pharmacy customers, who said they had received crushed pills, damaged vials and/or temperature-sensitive drugs in flimsy packaging without temperature indicators. Some customers told NBC they had to plead with pharmacies to send replacement drugs after they received medication that was too warm or cold. Further, many customers reported feeling trapped because they have no affordable alternative to mail-order delivery.
One interviewee, Las Vegas resident Megan Becker, receives a monthly package containing an injection to prevent debilitating migraines. On a 95-degree evening in June, Becker reported opening her package, which was a day late, to find that the enclosed ice packs had melted and that the temperature-sensitive medication felt warm to the touch. Becker said her insurance plan provides her with little choice: get the medicine for roughly $50 per month by mail through Express Scripts, or pay more than $600 out of pocket to get it at a local pharmacy.
North Carolina resident Erica Dean told NBC that the health of her daughter, Sophie, declined after her insurance company mandated that the family switch from a specialty pharmacy to Express Scripts. Shortly after she was born with cystic fibrosis, Sophie Dean was prescribed a pancreatic enzyme to help her digest food and absorb nutrients. The required pharmacy switch occurred in 2015, when Sophie was 8, and the enzyme was shipped, without a temperature indicator, in cardboard boxes or plastic bags, according to the family, and Sophie began suffering from debilitating stomach aches and a loss of appetite. When Sophie was hospitalized in 2017 for severe lung inflammation, she regained her appetite and had significantly less discomfort at mealtimes. Erica Dean explained that this coincided with Sophie being placed on the hospital’s supply of enzymes. The family was subsequently able to secure an exception allowing them to fill the prescription at a local pharmacy, and Sophie has thrived ever since, according to Erica Dean.
“Even before mail-order pharmacies, when it came to enzymes, we very explicitly told families never to leave them in their cars, never to leave them in a hot spot in the house,” Dr. Greg Sawicki, an Associate Professor of Pediatrics at Harvard Medical School, told NBC. “It could have very much been that the enzymes were denatured or not working effectively because they were not being stored or shipped properly.”
Wendy Barnes, Express Scripts’ Head of Home Delivery, assures that if a drug is damaged during transit, the company will expedite a replacement to the customer. When patient issues arise, “our team works quickly to resolve them,” she said. “While we are getting it right the majority of the time, any time we’re not, we absolutely need to do better.”
Proving a drug was damaged is challenging
While it’s well-documented that certain drugs may be less effective or even harmful if they are exposed to extreme temperatures, it’s nearly impossible to provide evidence that this occurred in a specific circumstance. This is because by the time a patient suspects they have been adversely impacted by damaged medication, it’s likely that the medicine will have been consumed or thrown away.
What to expect from mail-order pharmacy
The pharmacy benefit managers that operate the three largest mail-order pharmacies — Express Scripts, CVS Caremark, and OptumRx — accounted for 72 percent of mail-order prescription revenue in 2019, and each says it uses specific packaging and other measures to protect temperature-sensitive medication from extreme highs and lows. However, most state pharmacy boards, which regulate mail-order pharmacies, do not have specific rules governing how medication is shipped, leaving it up to pharmacies to ensure safe handling, according to NBC. Mail-order customers ought to remain aware of their prescriptions’ temperature requirements and how their online pharmacy controls the temperature throughout the process.
