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Abstract
Objective: To determine revealed pharmacy preference and predictors among
patients enrolled in a pharmacy benefit that offered a 90-day supply of prescriptions
via mail service and community pharmacy channels, with no differences in out-ofpocket costs.
Design: Retrospective cohort study.
Setting: United States in 200809.
Patients: 324,968 commercially insured participants enrolled in plans that required use of mail service pharmacy for maintenance medications.
Intervention: Implementation of a pharmacy benefit design with optional use of
either mail service or community pharmacy for 90-day supply prescriptions.
Main outcome measures: Selection rates of mail service and community pharmacy and adjusted odds ratios for predicting community pharmacy for selected characteristics.
Results: In the first 4 months of the benefit design, 31.8% of participants previously mandated to use mail service pharmacy elected to fill 90-day prescriptions
at community pharmacies. Selection of community pharmacy ranged from a low of
23.7% (previous mail service pharmacy users) to 66.3% (previous community pharmacy users). Among those initiating therapy, 44.3% selected community pharmacy
for their new prescriptions, and among those with no previous mail use, 68% selected
community pharmacy for new prescriptions. Preference for community/mail service
pharmacy was dependent on numerous characteristics, including age, gender, household income, region, driving distance (time), and concomitant medication use.
Conclusion: Patient behavior indicates that certain patients prefer to access
prescription medications via mail service and others through community pharmacy
channels. Restrictive benefit designs that incentivize patients to use less preferable
pharmacy channels may adversely affect patient convenience, which could have the
unintended consequence of reducing medication use and adherence.
Keywords: Pharmacy benefit design, revealed preference, mail service pharmacy.
J Am Pharm Assoc. 2011;51:5057.
doi: 10.1331/JAPhA.2011.09161
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educing barriers to the appropriate use of and adherence to essential medications for chronic conditions is
of paramount importance to insurers and policy makers.
Patients may encounter numerous barriers to medication use,
including elevated out-of-pocket costs, inadequate medication
education, and complexity of therapy.1 One barrier that pharmacy benefits managers (PBMs) can influence is convenience
of access to medications.
For patients who are frail, have limited transportation
services, prefer receiving 90-day supplies, or prefer the convenience of home delivery, mail service pharmacies may simplify access to essential medications. For patients who prefer
the convenience of a community pharmacy, prefer face-to-face
interactions with pharmacists, or are intimidated by the enrollment or ordering process in a mail service pharmacy system,
community pharmacies may be a preferable distribution channel for medications.2
PBMs must weigh the potential value of increased convenience against the potential costs of providing access through
different distribution channels. Increasingly, mail service
pharmacy options are promoted as a way to improve efficiency
and reduce prescription drug costs for payers, and 96.7% of
employers now offer a mail service pharmacy option.3 A 2003
Government Accounting Office report highlighted the financial
value of mail service pharmacy to organizations underwriting
At a Glance
51
Objectives
We sought to determine revealed pharmacy preference and factors associated with pharmacy selection. The patients studied
were newly enrolled in a plan that allowed them to purchase
90-day supplies of chronic medications at either mail service
or community pharmacies, with no differences in out-of-pocket
costs for either channel. This provided us with an opportunity
to study, in isolation, patient preference for distribution channel. We studied actual behavior in cohorts of patients who had
previously used or not used mail service pharmacy. We also
evaluated predictors of behavior such as sociodemographic
characteristics and driving distance to the nearest participating pharmacy. A better understanding of patient preferences
and characteristics associated with those preferences will
have important implications for employers and insurers that
create benefit designs to support appropriate use and adherence.
Methods
This retrospective cohort study examined the pharmacy selection patterns of patients whose pharmacy benefit plan was
expanded from a mandatory or incentivized mail service pharmacy design in 2008 to a plan, beginning on January 1, 2009,
that required 90-day supply prescriptions for maintenance
medications but allowed the participant to select either a local community pharmacy (i.e., CVS/pharmacy) or mail service
pharmacy with no difference in copayment.
Mandatory and incentivized mail service pharmacy designs
maximize mail service pharmacy use by restricting access to
community pharmacies. Under mandatory mail service pharmacy design, participants can fill a prespecified number of
30-day prescriptions (typically two) before being required to
transfer the prescriptions to a 90-day supply dispensed by a
mail service pharmacy. Under incentivized mail service pharwww.japha.org
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Research
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Class name
Sulfonylureas
Biguanides
Thyroid hormones
Cardioselective beta blockers
Calcium channel blockers
Angiotensin-converting enzyme inhibitors
Angiotensin II receptor blockers
Antihypertensive combinations
Loop diuretics
Thiazide diuretics
HMG CoA reductase inhibitors (statins)
Sympathomimetics
Proton pump inhibitors
Prostatic hypertrophy agents
Selective serotonin reuptake inhibitors
Nonsteroidal anti-inflammatory agents
Anticonvulsants
Potassium
Coumarin anticoagulants
Platelet aggregation
Results
The study included a total of 324,968 patients. Previous mail
users (n = 239,668) were 53.4% women, had a mean age of 65
years, and had a mean of 3.9 active prescriptions for mainteJournal of the American Pharmacists Association
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Table 2. Characteristics of study population in study assessing revealed preference for community and mail service pharmacy
Characteristic
n
Age (years)
<55
5564
6574
75
Gender
Women
Men
Region
Midwest
Northeast
South
West
Median household income ($)
<35,000
35,00040,000
40,00155,000
>55,000
Plan design transition
Incentivized to incentivized
Incentivized to mandatory
Mandatory to mandatory
No. active maintenance GPI4
0
12
34
5
Baseline mail service pharmacy use
No
Yes
CVS/pharmacy proximity (min)
5
610
1115
1620
2125
2630
>30
Therapy initiator
No. (%)
45,288
11,142 (24.6)
10,629 (23.5)
9,723 (21.5)
13,794 (30.5)
52,039 (21.7)
56,880 (23.7)
53,167 (22.2)
77,582 (32.4)
15,724 (39.3)
9,111 (22.8)
6,293 (15.7)
8,884 (22.2)
23,824 (52.6)
21,464 (47.4)
127,921 (53.4)
111,747 (46.6)
21,177 (52.9)
18,835 (47.1)
10,564 (23.3)
8,767 (19.4)
21,268 (47.0)
4,689 (10.4)
64,160 (26.8)
47,431 (19.8)
101,894 (42.5)
26,183 (10.9)
8,048 (20.1)
8,334 (20.8)
20,040 (50.1)
3,590 (9.0)
12,105 (26.7)
7,270 (16.1)
14,565 (32.2)
11,348 (25.1)
59,214 (24.7)
38,059 (15.9)
78,175 (32.6)
64,220 (26.8)
10,081 (25.2)
5,924 (14.8)
12,723 (31.8)
11,284 (28.2)
13,179 (29.1)
166 (0.4)
31,943 (70.5)
79,328 (33.1)
924 (0.4)
159,409 (66.5)
14,205 (35.5)
159 (0.4)
25,646 (64.1)
7,894 (17.4)
12,765 (28.2)
10,526 (23.2)
14,013 (30.9)
11,633 (4.9)
71,227 (29.7)
71,205 (29.7)
85,603 (35.7)
4,038 (10.1)
14,604 (36.5)
9,866 (24.7)
11,504 (28.8)
10,614 (23.4)
34,674 (76.6)
0
239,668 (100)
21,626 (54.0)
18,386 (46.0)
18,799 (41.5)
9,404 (20.8)
3,472 (7.7)
2,419 (5.3)
1,673 (3.7)
1,444 (3.2)
8,077 (17.8)
94,829 (39.6)
49,382 (20.6)
18,158 (7.6)
12,997 (5.4)
9,094 (3.8)
7,827 (3.3)
47,381 (19.8)
18,579 (46.4)
8,926 (22.3)
2,848 (7.1)
1,928 (4.8)
1,231 (3.1)
1,102 (2.8)
5,398 (13.5)
nance medications during the baseline period. The most common drug classes were statins (filled by 37.1% of participants),
proton pump inhibitors (20.1%), angiotensin-converting enzyme inhibitors (17.7%), and thyroid hormones (15%). Previous community pharmacy users were substantially younger
and had fewer concomitant medications but were similar regarding other demographics. The therapy initiator cohort was
slightly younger (63 years of age) but demographically similar
to the previous mail service pharmacy cohort. However, the
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10,408 (55.4)
5,053 (53.7)
1,629 (46.9)
1,013 (41.9)
619 (37.0)
479 (33.2)
881 (10.9)
8,391 (44.6)
4,351 (46.3)
1,843 (53.1)
1,406 (58.1)
1,054 (63.0)
965 (66.8)
7,196 (89.1)
5,431 (41.2)
81 (48.8)
14,570 (45.6)
7,748 (58.8)
85 (51.2)
17,373 (54.4)
7,210 (68.0)
12,780 (36.9)
4,919 (40.6)
2,980 (41.0)
6,441 (44.2)
5,742 (50.6)
7,186 (59.4)
4,290 (59.0)
8,124 (55.8)
5,606 (49.4)
3,389 (32.0)
21,817 (63.1)
3,694 (35.0)
4,415 (50.4)
10,538 (49.5)
1,435 (30.6)
6,870 (65.0)
4,352 (49.6)
10,730 (50.5)
3,254 (69.4)
4,651 (58.3)
6,160 (48.3)
4,324 (41.1)
4,947 (35.3)
10,193 (42.8)
9,889 (46.1)
13,631 (57.2)
11,575 (53.9)
3,333 (41.7)
6,605 (51.7)
6,202 (58.9)
9,066 (64.7)
6,149 (55.2)
5,118 (48.2)
3,978 (40.9)
4,837 (35.1)
4,993 (44.8)
5,511 (51.8)
5,745 (59.1)
8,957 (64.9)
65,398 (69.0)
34,532 (69.9)
13,514 (74.4)
10,086 (77.6)
7,474 (82.2)
6,595 (84.3)
45,370 (95.8)
0
182,969 (76.7)
8,027 (69.0)
54,964 (77.2)
54,454 (76.5)
65,524 (76.5)
62,404 (78.7)
627 (67.9)
119,931 (75.2)
46,555 (78.6)
29,531 (77.6)
59,456 (76.1)
47,427 (73.9)
52,438 (81.7)
34,853 (73.5)
73,244 (71.9)
22,434 (85.7)
98,684 (77.1)
84,285 (75.4)
38,765 (74.5)
42,879 (75.4)
40,188 (75.6)
61,137 (78.8)
29,431 (31.0)
14,850 (30.1)
4,644 (25.6)
2,911 (22.4)
1,620 (17.8)
1,232 (15.7)
2,011 (4.2)
0
55,714 (23.3)
3,606 (31.0)
16,263 (22.8)
16,751 (23.5)
20,079 (23.5)
16,924 (21.3)
297 (32.1)
39,478 (24.8)
12,659 (21.4)
8,528 (22.4)
18,719 (23.9)
16,793 (26.1)
11,722 (18.3)
12,578 (26.5)
28,650 (28.1)
3,749 (14.3)
29,237 (22.9)
27,462 (24.6)
13,274 (25.5)
14,001 (24.6)
12,979 (24.4)
16,445 (21.2)
Characteristic
Age (years)
<55
5564
6574
75
Gender
Women
Men
Region
Midwest
Northeast
South
West
Median household income ($)
<35,000
35,00040,000
40,00155,000
>55,000
Plan design transition
Incentivized to incentivized
Incentivized to mandatory
Mandatory to mandatory
No. active maintenance GPI4
0
12
34
5
Baseline mail service pharmacy use
No
Yes
CVS/pharmacy proximity (min)
5
610
1115
1620
2125
2630
>30
4,331 (23.3)
2,308 (25.9)
875 (30.7)
702 (36.4)
516 (41.9)
495 (44.9)
4,256 (78.8)
4,556 (21.1)
8,927 (48.6)
943 (23.4)
4,139 (28.3)
3,396 (34.4)
5,005 (43.5)
5,231 (36.8)
42 (26.4)
8,209 (32.0)
3,716 (36.9)
2,221 (37.5)
4,316 (33.9)
3,230 (28.6)
3,492 (43.4)
2,269 (27.2)
5,718 (28.5)
2,004 (55.8)
7,502 (35.4)
5,981 (31.8)
4,367 (27.8)
2,903 (31.9)
2,336 (37.1)
3,877 (43.6)
14,248 (76.7)
6,618 (74.1)
1,973 (69.3)
1,226 (63.6)
715 (58.1)
607 (55.1)
1,142 (21.2)
17,070 (78.9)
9,459 (51.4)
3,095 (76.6)
10,467 (71.7)
6,470 (65.6)
6,499 (56.5)
8,974 (63.2)
117 (73.6)
17,437 (68.0)
6,365 (63.1)
3,703 (62.5)
8,407 (66.1)
8,054 (71.4)
4,556 (56.6)
6,065 (72.8)
14,322 (71.5)
1,586 (44.2)
13,675 (64.6)
12,854 (68.2)
11,357 (72.2)
6,208 (68.1)
3,957 (62.9)
5,007 (56.4)
Table 3. Distribution of demographic, patient, and plan design characteristics by selection of mail service or community pharmacy for 90-day supply prescriptions, by population cohort
Research
revealed pharmacy preference
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Discussion
This study highlights that when pharmacy benefit design does
not preferentially support one pharmacy distribution channel,
both community pharmacy and mail service pharmacy options
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Research
Table 4. Adjusted odds for selecting community pharmacy for the distribution of 90-day supply maintenance medications, by
cohort
Characteristic
Baseline mail service pharmacy use
Yes (referent)
No
Gender
Men (referent)
Women
Age (years)
<55 (referent)
5564
6574
75
Median household income ($)
<40,000 (referent)
40,00055,000
>55,000
Concurrent maintenance drugs
0 (referent)
12
34
5
Region
South (referent)
Midwest
Northeast
West
Driving distance (min)
>30 (referent)
2630
2125
1620
1115
610
5
Plan design
Incentivized to incentivized
(referent)
Incentivized to mandatory
Mandatory to mandatory
Therapy initiators Previous mail service pharmacy users Previous community pharmacy users
OR (95% CI)
OR (95% CI)
OR (95% CI)
1.00
3.77 (3.544.01)
NA
NA
1.00
3.77 (3.573.98)
1.00
0.92 (0.880.96)
1.00
0.92 (0.900.94)
1.00
0.89 (0.850.93)
1.00
0.98 (0.931.05)
0.89 (0.830.94)
0.71 (0.670.76)
1.00
1.01 (0.981.04)
1.03 (1.001.06)
0.85 (0.830.88)
1.00
1.11 (1.041.19)
1.07 (0.991.15)
0.87 (0.810.93)
1.00
1.02 (0.971.07)
1.10 (1.041.16)
1.00
1.03 (1.001.05)
1.01 (0.981.03)
1.00
1.07 (1.011.13)
1.18 (1.111.26)
1.00
1.36 (1.271.46)
1.33 (1.231.43)
1.15 (1.061.24)
1.00
0.68 (0.650.71)
0.73 (0.700.77)
0.75 (0.720.79)
1.00
1.07 (0.981.17)
1.23 (1.121.35)
1.05 (0.951.16)
1.00
0.64 (0.600.67)
0.80 (0.750.84)
0.48 (0.450.52)
1.00
0.65 (0.630.66)
0.75 (0.730.77)
0.48 (0.460.50)
1.00
0.58 (0.550.62)
0.75 (0.700.80)
0.33 (0.300.36)
1.00
1.50 (1.311.73)
1.83 (1.602.08)
2.36 (2.122.62)
2.83 (2.603.08)
3.62 (3.383.87)
4.05 (3.824.29)
1.00
1.37 (1.271.48)
1.59 (1.481.70)
2.21 (2.092.33)
2.63 (2.522.74)
3.31 (3.203.43)
3.59 (3.483.69)
1.00
1.66 (1.431.94)
1.92 (1.662.22)
2.62 (2.322.96)
3.40 (3.083.74)
4.19 (3.894.52)
4.88 (4.595.19)
1.00
1.26 (0.911.76)
1.27 (1.201.35)
1.00
1.62 (1.411.88)
1.22 (1.181.26)
1.00
1.57 (1.062.31)
1.36 (1.291.43)
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Limitations
Interpretation of our results is limited by several issues. We assessed patient selection of community or mail service pharmacy
from administrative pharmacy claims and did not directly survey patients. Community pharmacy convenience was assessed
by driving distance from a patients home address to the nearest
CVS/pharmacy location. However, the nearest and most convenient pharmacy may have been proximal to a workplace location (data unavailable in the administrative records) or to another community pharmacy. Because the community pharmacy
option was limited to CVS/pharmacy only, our results likely
underestimate the actual preference for community pharmacy.
We did not assess pharmacy channel switching behavior, which
would require substantially more follow-up time to profile thoroughly. Finally, our analysis was conducted in a population of
commercially insured beneficiaries, and we cannot generalize
our findings to uninsured patients or patients who are enrolled
in Medicaid or other government-sponsored insurance plans.
Conclusion
A pharmacy benefit design that allows patients the choice of
community or mail service pharmacy without any direct financial incentive (via copay differentials) resulted in selection of
both mail service and community pharmacy channels. These
results highlight the importance of constructing pharmacy
benefit designs that provide access to both channels in order
to support convenient, patient-centered access to medications.
Patient preference for access to medications via mail service
or community pharmacy depends on numerous characteristics,
including age, gender, household income, geographic region of
residence, driving distance (time) to community pharmacy location, and concomitant medication use. An important implication
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