Mail order pharmacies have exploded in popularity in recent years, but many pharmacists and patients are starting to notice something isn’t quite right. The convenience of receiving prescriptions at home is appealing, but it’s coming at a hidden cost. Over the past decade, mail order pharmacy sales have more than doubled, growing from $86 billion to over $206 billion, yet the number of prescriptions filled through mail order only increased by 11%. That raises some serious questions: Why are costs rising so dramatically if the volume isn’t increasing?

A major factor driving this boom is the influence of Pharmacy Benefit Managers (PBMs), who manage prescription drug benefits for healthcare plans, Medicare, and large employers. PBMs dominate the market and have been incentivizing patients to use mail order pharmacies, claiming it saves money and provides greater convenience. But behind the scenes, the truth is far more complicated.

The pitch for mail order pharmacies was simple: By cutting overhead costs associated with brick-and-mortar stores and operating on a larger scale, these pharmacies could offer medications at lower prices. But in reality, mail order prescriptions are often marked up by startling amounts. For example, a generic antidepressant that costs around $12 at a retail pharmacy could be billed at up to $100 through a mail order service — an 800% markup. And that’s not even the worst case. For brand name drugs, the markup can be as much as 35 times higher. So, how does this happen?

The answer lies in something called the “spread” — the difference between what a PBM charges a health plan for a drug and what it reimburses the pharmacy for that same drug. PBMs profit from this spread, and when they own mail order pharmacies, they control both sides of the transaction. This means they can sell medications to themselves for whatever price they choose, further inflating costs.

What’s even more concerning is the lack of transparency in the pricing structure. Many employers, health plans, and patients are left in the dark about how much PBMs are actually marking up drug prices. It’s like going to the grocery store and hoping for the best without knowing the actual cost of what you’re buying.

But the dangers of mail order pharmacies don’t end with price hikes. Temperature control during shipping is another issue that’s rarely discussed. Medications need to be stored within specific temperature ranges to remain effective, typically between 68 and 77 degrees Fahrenheit. But when medications are shipped across the country, they’re often exposed to extreme temperatures, especially in places like the desert or mountainous regions. Extreme heat or cold can damage the chemical composition of medications, making them ineffective or even harmful.

A study by the Journal of American Pharmacists Association found that only a third of the time, medications shipped by mail order were within safe temperature ranges. The rest of the time, they were exposed to potentially dangerous conditions. Yet, there are no federal regulations requiring temperature monitoring during shipping. While some advocates are pushing for change, there is no consistent system in place to ensure that medications are delivered safely and effectively.

This lack of oversight and regulation is a serious issue that no one seems to be adequately addressing. Patients, doctors, and pharmacists may never even realize that medications ordered through mail pharmacies are compromised. And to make matters worse, PBMs continue to charge for medications that may not even work.

As a profession, we need to have an open conversation about these issues and push for greater accountability. If mail order pharmacies and PBMs continue to operate unchecked, patients could suffer, and pharmacists may continue to see their practices undermined by skyrocketing costs and compromised patient care.

This is a topic that affects us all. If you’re currently working in a mail order pharmacy or dealing with PBMs in any capacity, it’s time to start asking tough questions. The status quo isn’t working, and it’s time to demand change before more patients are hurt or overcharged.