Trends in Mail-Order Pharmacy Use in the U.S. From 1996 to 2018: An Analysis of the Medical Expenditure Panel Survey

  • Duy Do
    Address correspondence to: Duy Do, PhD, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford University, 1701 Page Mill Road, Palo Alto, CA 94304.
    Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford University, Palo Alto, California

    Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
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  • Pascal Geldsetzer
    Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford University, Palo Alto, California

    Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
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      The use of mail-order pharmacies is generally associated with lower healthcare costs and improved medication adherence. To promote the use of mail-order pharmacies, it is important to understand the time trends in their use and whether these trends vary by population subgroups.


      This study used the 1996–2018 Medical Expenditure Panel Survey to determine the annual prevalence of mail-order pharmacy use (defined as purchasing ≥1 prescription from a mail-order or online pharmacy) among U.S. adult prescription users and its variation by population characteristics. Logistic regression was used to determine the correlates of mail-order pharmacy use. Results were presented for medications and therapeutic classes most commonly purchased by mail-order pharmacy exclusive users. Analyses were conducted in December 2020.


      The annual prevalence of mail-order pharmacy use among U.S. adult prescription users increased from 10.2% (95% CI=9.3, 11.1) in 1996 to 17.0% (95% CI=15.9, 18.1) in 2005 and then declined to 15.7% (95% CI=14.9, 16.6) by 2018. Absolute differences in the prevalence of use by race/ethnicity, education, and health insurance coverage widened over time, whereas they remained stable when stratifying by sex, age, marital status, region, limitations in daily activities, pain interference, health status, number of chronic conditions, and access to medical care. Among mail-order pharmacy exclusive users, the 3 most commonly purchased medications were atorvastatin (16.7%), levothyroxine (13.6%), and lisinopril (13.1%); the 3 most commonly purchased therapeutic classes were cardiovascular agents (57.9%), metabolic agents (52.1%), and central nervous system agents (29.6%).


      The prevalence of mail-order pharmacy use has declined in recent years and has shown significant variation across population subgroups. Future research should examine whether the declining trends and variation in use may influence the management of chronic conditions and the disparities in health and healthcare costs.
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        • Federal Trade Commission
        Pharmacy benefit managers: ownership of mail-order pharmacies: a Federal Trade Commission report.
        Federal Trade Commission, Washington, DCAugust 2005 (Published)
        • IQVIA
        Medicine spending and affordability in the U.S.: understanding patients’ costs for medicines.
        IQVIA, Durham, NCAugust 4, 2020 (Published)
        • Carroll NV
        • Brusilovsky I
        • York B
        • Oscar R.
        Comparison of costs of community and mail service pharmacy.
        J Am Pharm Assoc (2003). 2005; 45: 336-343
        • Devine S
        • Vlahiotis A
        • Sundar H.
        A comparison of diabetes medication adherence and healthcare costs in patients using mail order pharmacy and retail pharmacy.
        J Med Econ. 2010; 13: 203-211
        • Schmittdiel JA
        • Karter AJ
        • Dyer W
        • et al.
        The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.
        J Gen Intern Med. 2011; 26: 1396-1402
        • Fein AJ.
        2013 Pharmacy market analysis: chains up, mail down.
        Drug Channels Institute, Philadelphia, PAMay 28, 2014 (Published)
        • Horgan C
        • Goody B
        • Knapp D
        • Fitterman L.
        The role of mail service pharmacies.
        Health Aff (Millwood). 1990; 9: 66-74
        • Rupp MT.
        Attitudes of Medicare-eligible Americans toward mail service pharmacy.
        J Manag Care Pharm. 2013; 19: 564-572
      1. Fein AJ. The 2020 economic report on U.S. Pharmacies and pharmacy benefit managers. Philadelphia, PA: Drugs Channels Institute. Published March 2021. Accessed December 6, 2020.

        • HHS, Center for Medicare & Medicaid Services (CMS)
        CMS manual system: pub. 100–18 Medicare prescription drug benefit manual.
        HHS, Center for Medicare & Medicaid Services (CMS), Baltimore, MDJuly 3, 2008 (Published)
        • Wu J
        • Davis-Ajami ML
        • Noxon V.
        Patterns of use and expenses associated with mail-service pharmacy in adults with diabetes.
        J Am Pharm Assoc (2003). 2015; 55: 41-51
        • Ma J
        • Wang L.
        Characteristics of mail-order pharmacy users: results from the Medical Expenditures Panel Survey.
        J Pharm Pract. 2020; 33: 293-298
        • Blackwell DL
        • Lucas JW
        • Clarke TC.
        Summary health statistics for U.S. adults: National Health Interview Survey, 2012.
        Vital Health Stat 10. 2014; : 1-161
        • Brodie M
        • Flournoy RE
        • Altman DE
        • Blendon RJ
        • Benson JM
        • Rosenbaum MD.
        Health information, the internet, and the digital divide.
        Health Aff (Millwood). 2000; 19: 255-265
        • Buchmueller TC
        • Levinson ZM
        • Levy HG
        • Wolfe BL.
        Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage.
        Am J Public Health. 2016; 106: 1416-1421
        • Fernandez EV
        • McDaniel JA
        • Carroll NV.
        Examination of the link between medication adherence and use of mail-order pharmacies in chronic disease states.
        J Manag Care Spec Pharm. 2016; 22: 1247-1259
      2. Phelan JE, Ergun D, Langer G, Holyk G. Medication adherence in America: a national report card. Alexandria, VA: National Community Pharmacists Association. Published June 2013. Accessed August 22, 2020.

        • Cubanski J
        • Biniek JF
        • Rae M
        • Damico A
        • Frederiksen B
        • Salganicoff A
        Mail delays could affect mail-order prescriptions for millions of Medicare part D and large employer plan enrollees.
        Kaiser Family Foundation, San Francisco, CAAugust 20, 2020 (Published)
        • Rashrash ME
        • Tomaszewski DM
        • Schommer JC
        • Brown LM.
        Consumers’ characteristics associated with the use of mail pharmacy services in the United States: findings from the 2015 National Consumer Survey on the Medication Experience.
        J Am Pharm Assoc (2003). 2017; 57: 206-210
        • Cohen JW
        • Cohen SB
        • Banthin JS.
        The medical expenditure panel survey: a national information resource to support healthcare cost research and inform policy and practice.
        Med Care. 2009; 47: S44-S50
        • Blewett LA
        • Drew JAR
        • Griffin R
        • Williams KC.
        IPUMS Health Surveys: Medical Expenditure Panel Survey, Version 1.1 [dataset]. Minneapolis, MN: IPUMS; 2019;
        • Goodman RA
        • Posner SF
        • Huang ES
        • Parekh AK
        • Koh HK.
        Defining and measuring chronic conditions: imperatives for research, policy, program, and practice.
        Prev Chronic Dis. 2013; 10: E66
        • Agency for Healthcare Research and Quality
        MEPS HC036: 19962017 pooled linkage variance estimation file.
        Agency for Healthcare Research and Quality, Rockville, MDAugust 2019 (Published)
        • Suda KJ
        • Hicks LA
        • Roberts RM
        • Hunkler RJ
        • Matusiak LM
        • Schumock GT.
        Antibiotic expenditures by medication, class, and healthcare setting in the United States, 2010–2015.
        Clin Infect Dis. 2018; 66: 185-190
        • Barbieri JS
        • Bhate K
        • Hartnett KP
        • Fleming-Dutra KE
        • Margolis DJ.
        Trends in oral antibiotic prescription in dermatology, 2008 to 2016.
        JAMA Dermatol. 2019; 155: 290-297
        • Choudhry NK
        • Shrank WH.
        Four-dollar generics–increased accessibility, impaired quality assurance.
        N Engl J Med. 2010; 363: 1885-1887
        • Mantwill S
        • Monestel-Umaña S
        • Schulz PJ.
        The relationship between health literacy and health disparities: a systematic review.
        PLoS One. 2015; 10e0145455
        • Rikard RV
        • Thompson MS
        • McKinney J
        • Beauchamp A.
        Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL).
        BMC Public Health. 2016; 16: 975
        • Kantor ED
        • Rehm CD
        • Haas JS
        • Chan AT
        • Giovannucci EL.
        Trends in prescription drug use among adults in the United States from 1999-2012.
        JAMA. 2015; 314: 1818-1831
      3. SHADAC analysis of the American Community Survey (ACS) Public Use Microdata Sample (PUMS) files, State Health Compare, SHADAC, University of Minnesota. Accessed April 26, 2021.

        • Fareed N
        • Swoboda CM
        • Jonnalagadda P
        • Walker DM
        • Huerta TR.
        Differences between races in health information seeking and trust over time: evidence from a cross-sectional, pooled analyses of HINTS data.
        Am J Health Promot. 2021; 35: 84-92
        • Mahmoudi E
        • Jensen GA.
        Diverging racial and ethnic disparities in access to physician care: comparing 2000 and 2007.
        Med Care. 2012; 50: 327-334
        • Desai R
        • Thakkar S
        • Fong HK
        • et al.
        Rising trends in medication non-compliance and associated worsening cardiovascular and cerebrovascular outcomes among hospitalized adults across the United States.
        Cureus. 2019; 11: e5389
        • Bleich SN
        • Jarlenski MP
        • Bell CN
        • LaVeist TA.
        Health inequalities: trends, progress, and policy.
        Annu Rev Public Health. 2012; 33: 7-40
        • Hopkins JS.
        Mail-order drug delivery rises during coronavirus lockdowns.
        The Wall Street Journal. May 12, 2020.;
        • Ipsos
        Topline and methodology: Axios/Ipsos poll – wave 22.
        Ipsos, Washington, DC2020 (Published)
        • Warren E.
        Rapidly increasing postal service delivery delays for mail-order prescription drugs pose health risks for millions of Americans. Staff Report Prepared for U.S. Senator Elizabeth Warren and U.S. Senator Bob Casey.
        Warren Senate, Washington, DCSeptember 2020 (Published)