FARGO -- North Dakotans who use Blue Cross Blue Shield health insurance may have received fliers from Amazon Pharmacy that describe how to get prescriptions through the mail.
The mailing says customers can save time and money by ordering medicine through Amazon Prime, which offers free delivery.
The move is part of a growing trend in U.S. health care, said Dr. Joel Farley, a professor and interim Pharmaceutical Care and Health Systems Department head at the University of Minnesota College of Pharmacy. Insurance companies across the country have increasingly encouraged customers to use -- or at least informed them about -- mail-order services as an option for getting medications, he said.
North Dakota Blue Cross Blue Shield, or BCBS, has offered a home delivery option for several years, Communications Director Melissa Richard said. Through its partnership with pharmacy benefit manager Prime Therapeutics, BCBS started using Amazon Pharmacy for its pharmaceutical mail service in 2023.
"We were hearing feedback from some of our employer groups that they felt like their employees didn't have enough awareness of the benefit," she said. "They asked us to devise a strategy to help improve awareness. That's how this mailer came to be."
The flier was sent to a small, targeted group of members, Richard said. The option makes access to medications more convenient and affordable to patients with limited options to access prescription drugs, she said.
Mike Schwab, North Dakota Pharmacists Association executive vice president, said he has concerns about home delivery services, including the possibility of undercutting local pharmacies.
"One thing that they haven't been shy about is pushing their mail-order options," Schwab said of BCBS. "It's not so much that Blue Cross is saying, 'Hey, did you know Amazon has a pharmacy? Why don't you check them out?' It's 'Hey, we've (BCBS) worked out a deal with Amazon and we would like to promote Amazon.' That's really what's going on."
Pharmacy benefit managers like Prime Therapeutics negotiate and manage prescription drug benefits and claims between health insurance companies and pharmacies.
Pharmacy benefit managers can keep purchases in-house and save money by working with home delivery services, Farley said.
Insurance companies and pharmacy benefit managers set the terms of a contract with pharmacies, often with "take it or leave it" terms, Schwab said. Pharmacies have little control when it comes to setting prices, he said.
"When it comes to the mail-order side, it obviously creates that volume shift," he said. "Depending on how many patients you might have that utilize that service, it could have a negative effect on your business."
Home delivery services are not impacted by North Dakota's pharmacy ownership law, which states a licensed pharmacist must have majority ownership of a pharmacy in North Dakota. For example, a pharmacy can be inside a Walmart as long as a licensed pharmacist in North Dakota owns at least 51% of the business.
North Dakotans rejected a measure in 2014 that would have nixed that law, with 59% saying no.
North Dakota law allows home delivery services for medications. Amazon Pharmacy has a license to operate in North Dakota as a home delivery service, Richard said.
The state Insurance Department said it doesn't have concerns regarding the mailers from Amazon Pharmacy.
"These are fairly common with insurance companies," Insurance Department spokesman Jacob Just said.
Employers decide which benefit plans to offer their workers, not Prime Therapeutics or BCBS, Richard said. Patients are allowed to choose whether they use it, she said.
"Blue Cross Blue Shield of North Dakota offers options to our members that are focused on driving affordability and patient outcomes across our available pharmacy relationships," she said. "We believe our role is to give our members options to access prescriptions in the most affordable, convenient way that is the best fit for them."
Richard said 0.5% of pharmaceutical claims at BCBS come from home delivery services. BCBS provides insurance to more than 450,000 people, according to the company's website.
"I will say that the overwhelming majority of our pharmacy claims are prescriptions that are filled through local pharmacies," Richard said. "This really doesn't represent a huge piece of the claims that we see."
Medications can be delivered to homes that are far away from local pharmacies, and patients can use one copay to cover 90 days' worth of medication instead of 30, she said.
That means fewer trips to the pharmacy and fewer copays for the patient to cover, Richard said. It also could increase the likelihood that patients will take their medication more regularly, she said.
"It's really helping to fill gaps," Richard said.
The shift to mail orders takes revenue away from local pharmacies, which can hurt them financially, Farley said.
In 2023, Americans spent $722.5 billion on prescription drugs, according to a study published in July by the National Institutes of Health.
Mail-order sales made up 28% of those expenditures, up almost 14% from 2022.
Mail-order was the second-highest sales category behind retail pharmacy sales, which accounted for 42% of prescription drug costs for Americans last year.
Schwab noted concerns about medications being delayed or lost in the mail, as well as sitting out in the elements and spoiling.
"Guess who fills in those care gaps?" Schwab said. "Typically, the pharmacies then do."
Pharmacy benefit managers may offer discounts and can waive copays for mail orders, Schwab said. Local pharmacies can't, he said.
"If you are going to create an additional service at what is perceived as a discounted price, you should allow your other competing pharmacies to offer that same type of offer," he said.
BCBS and Prime Therapeutics don't waive copays, Richard said.
The prescription drug home delivery industry is growing, Farley said. He acknowledged the convenience of mail orders for remote areas, and it helps individuals with chronic conditions.
But it doesn't work very well with immediate needs, he said.
"If I have a child who has an ear infection and is in a lot of discomfort, I don't want to have to wait for a prescription to be mailed to my house," Farley said.
He called local pharmacies a "local resource."
"If local pharmacies don't have enough revenue to continue operation, we are at risk of losing these local resources," he said. "That loss means we also lose all of the other benefits that pharmacies bring to the community."