UnitedHealth Group’s pharmacy mailed Medicare recipient Bill Zielinski so many refills of the cholesterol drug atorvastatin that his unused stash could last a year on the pill-a-day regimen his doctor ordered.
Excessive refilling is common practice at U.S. mail-order pharmacies, a Journal analysis of Medicare prescription data found, flooding the homes of seniors with extra drugs. Too-frequent refills by all U.S. pharmacies cost Medicare and patients $3 billion between 2021 and 2023, the analysis found.
“It’s awful how much waste that is,” said Pamela Schweitzer, a pharmacist and former assistant U.S. surgeon general. And for seniors, she said, “it’s a terrible idea to have all that medication sitting around that you’re not taking.”
Some of the extra pills, which include millions of doses of muscle relaxants and antipsychotics, could lead to accidents such as taking too much of a medication or taking the wrong one, pharmacists said.
The cost of excess refilling increased during the pandemic after regulators relaxed rules limiting early refills, and consumers increasingly turned to mail-order pharmacies.
Mail-order pharmacies filled just 9% of Medicare prescriptions in the three-year period examined by the Journal, but accounted for 37% of the excess dispensing, the analysis showed. Such pharmacies often send 90-day refills automatically when patients are near the end of their earlier supplies.
Many people who take prescription drugs find it convenient to get three-month supplies and to get refills before they are down to the last few pills. The problem arises when repeated early refilling causes the oversupply to keep growing, resulting in a one-pill-a-day patient, for example, getting more than 400 pills a year.
The Journal’s analysis counted as excess only dispensed prescription drugs that exceeded a month’s supply over up to three years’ worth of prescriptions.
The largest U.S. mail-order pharmacies are owned by conglomerates that operate health insurance businesses as well. Those include UnitedHealth, Humana and Aetna owner CVS Health. Some of the pharmacy operators said their goal was to ensure patients get needed medications on time and adhere to their prescriptions. They said patients must opt-in to automatic refills, are notified before orders ship, and can pause prescriptions if desired.
UnitedHealth said its efforts can result in occasional medication overages. “The alternative—members becoming gravely ill due to lack of medication—is far more harmful to patients and costly to the health system,” a company spokesman said. He said early refills aren’t a waste because members can retain the medications and decline future refills.
Pharmacies make money through fees for dispensing the drugs and markups on their cost, so they have an incentive to dispense more. While walk-in pharmacies don’t make money until customers show up for their drugs, mail-order ones process the transactions when the automated shipments go out.
The Journal analysis is based on Medicare prescription records accessed under a research agreement with the federal government. The records include details of each individual prescription for more than 50 million Medicare recipients between 2021 and 2023, but don’t identify individuals.
Doctors and patients said such earlier-refilling practices aren’t limited to Medicare patients, and that it also happens with people covered by employer-sponsored plans. The Journal analysis doesn’t cover those private plans.
Medicare spends more than $100 billion a year on drug benefits. The Journal’s analysis showed substantial excessive refilling of several common drugs. In the three-year period, pharmacies dispensed to Medicare patients more than 30 extra days of diabetes treatment Jardiance almost 200,000 times, costing taxpayers and patients $111 million. Cheaper generics added up, too, with extra atorvastatin supplies costing $15.6 million.
The Medicare agency requires drug plans to set limits on early prescription refills. Some insurers require patients to wait until they are 75% of the way through a prior supply, or day 68 for a 90 refill. The federal government relaxed its rules for refills for Medicare recipients as part of its response to the Covid pandemic starting in 2020, allowing pharmacies to refill drugs earlier for a time.
The Journal analysis found that over the three-year period, UnitedHealth’s mail-order pharmacies sent refills sooner than the 68-day threshold 11% of the time, almost nine times the rate of all other Medicare pharmacies.
Risk Factor
For some drugs, UnitedHealth sent early refills more frequently than that. More than 30% of the roughly 89,000 90-day refills of the muscle relaxant tizanidine shipped by UnitedHealth’s Optum pharmacy arm were processed sooner than 68 days after the prior shipment. UnitedHealth also sent other muscle relaxants, including the generic form of Flexeril, early.
Doctors often prescribe muscle relaxants, which carry the risk of abuse and dependence, to be taken as needed. Excessive refilling means patients who take the medicines infrequently could amass even bigger surpluses.
The federal Medicare agency declined to comment on the Journal’s analysis but said it viewed early refills of drugs like the muscle relaxants as a “potential safety and program integrity signal that warrants careful monitoring.”
UnitedHealth and rival insurer Humana’s CenterWell pharmacy both sent early refills of some psychiatric drugs like Seroquel, an antipsychotic, at higher rates than many other drugs.
UnitedHealth sent $142 worth of excess medications per Medicare recipient served during the three-year period, the highest amount of any major pharmacy operator. Humana ranked second, with $90 worth of extra medication per Medicare recipient.
Both companies said that after the pandemic-era emergency rules ended in 2023, they denied more early refills than in the period the Journal studied.
UnitedHealth said it blocked up to five times as many early refills in 2024 as in 2021 and 2022. “The data does not reflect current practices,” the spokesman said.
Humana said its current protocols “strike the right balance, allowing sufficient time to fill and ship prescriptions and supporting medication adherence without encouraging stockpiling.”
A Walgreens spokeswoman said the store-based pharmacy company has controls to prevent refills beyond physicians’ orders. CVS Health declined to comment.
Joe Mulvehill, a New York doctor who visits many elderly patients in their homes, said he regularly finds drawers or shoeboxes full of pills, often sent by mail. One patient had more than 50 bottles stashed around her apartment, mostly from mailed prescriptions received by her and her late husband. After his first visit, Mulvehill typically hauls away bags of medications that are no longer current to ensure patients aren’t taking the wrong drugs or dosages.
“They just get piled on, they keep getting them,” he said. “The more they have, the more confused they are about what they are taking.”
Pharmacists and doctors said the piles of old mail-order prescriptions pose risks to older patients, particularly those with memory or vision challenges. Elderly patients with extra pills might keep taking a drug or a dosage that their doctor no longer prescribes, said Donna Bartlett, a geriatric pharmacist and professor at the Massachusetts College of Pharmacy and Health Sciences.
They also might mistakenly double up on a medication if a mail-order pharmacy switches generic manufacturers and a drug begins coming in a different-colored pill that appears to be a different prescription.
Some seniors have multiple family members or caregivers who might be mistaken about which prescriptions are current.
“Oversupply can really be a problem,” Bartlett said. Taking too much Seroquel, the antipsychotic, the analysis found, can often cause blood pressure to drop when it is refilled early.
Daniel Duffy, a 55-year-old Texas construction-materials salesman who gets health insurance through his wife’s employer, said he noticed last year that a mail-order pharmacy operated by Cigna unit Express Scripts was sending him too many bottles of pills, including the antidepressants trazodone and duloxetine.
“I’ll get my 90-day supply, then I’ll get my next refill at day 75. Now I have 15 extra,” he said. “Every time, there are 15 extra pills.”
Duffy shared records showing that Express Scripts sometimes sent him pills at an even higher rate, including 360 days’ worth of lamotrigine over 169 days last year. The extras accumulated in part because his doctor upped his dosage in October, seven days after he received an autoshipped 90-day refill. The company sent 90 more pills 72 days later, in early December.
“I know her company is paying for it,” Duffy said of his wife’s insurance. “I’m like, why?”
Soon after, he canceled the mail-order refills, and when his stash ran low months later, he started picking up his pills at a local Walmart, pharmacy records show.
An Express Scripts spokeswoman said the company is committed to reducing healthcare waste, “so our refill process also accounts for the cumulative amount of medication that a patient has on hand.” She said the company requires patients to sign up for automatic refills and notifies them before each shipment.
Owned By Insurers
In Medicare, private insurers oversee taxpayer-funded drug benefits. In recent years, those insurers, including UnitedHealth and Humana, have bought up pharmacies, doctors’ offices, and other health-services providers.
This means that insurers are increasingly paying their own pharmacy units for the drugs they dispense. In the process, revenue shifts from their closely regulated insurance arms, where profits are effectively limited by federal law, to their pharmacy arms, where profits aren’t restricted.
Some former UnitedHealth executives and insurance-industry actuaries said early prescription refills could help improve the performance of health plans in industrywide quality ratings, including ones that measure whether patients are taking medicines as prescribed and whether customers are satisfied.
UnitedHealth said medication adherence is important to the quality ratings, but that its priority is its members’ health.
Congress requires private insurers that oversee Medicare’s drug benefit to cover 90-day prescription refills at bricks-and-mortar pharmacies as well as mail-order pharmacies, but long-term refills are less common at walk-in facilities. The requirement was intended to level the playing field between the competing businesses, lawmakers said at the time.
The portion of Medicare prescriptions filled by mail-order pharmacies increased to 9.1% at the end of 2023, from 7.7% at year-end 2018, Medicare data shows.
Safely disposing of excess prescription pills isn’t a simple matter. Government regulations prevent nursing homes, assisted-living facilities, and others from throwing them out with normal garbage. So-called reverse distributors contract with healthcare facilities to collect extra, unused pills for disposal.
RemediChain, part of a nonprofit, gets hundreds of bottles a month full of patients’ unused, sealed medications, which it offers free to people who have prescriptions and are in need. Many donations are from people getting rid of extra prescriptions shipped by mail-order pharmacies, or from the families of patients who have died, said Phil Baker, a pharmacist who leads the charity.
“They know they’re valuable, so they just pile them up,” said Baker. “They don’t want to flush them down the toilet, they don’t want to throw them in the trash.”
The Journal’s analysis concluded that Medicare patients who died from 2021 to 2023 left behind refill overages worth $240 per person. Patients who died after receiving drugs from UnitedHealth’s pharmacy arm left behind $357 worth, on average.
Insurers are supposed to obtain opt-in agreements from Medicare patients for prescriptions to be automatically refilled.
Zielinski, the retiree getting early refills of atorvastatin, said he didn’t recall whether UnitedHealth’s pharmacy arm asked him for permission to start automatically refilling the drugs.
The 74-year-old retired mortgage officer in Oxford, Conn., said he generally followed his doctor’s orders to take one statin pill a day. “I might miss a day here and there,” he said, “but certainly not 300 times.”
During a 10½ month period ending earlier this year, UnitedHealth’s mail-order pharmacy shipped him 450 of the pills, records show.
UnitedHealth said those orders included an early refill due to a glitch in December 2024, and that Zielinski received an extra 56 pills during that period. It said his refills for the statin prescription were set to process 85% of the way through his prior prescription, per its standard practice, and were otherwise shipped accordingly since 2017.
Refilling a 90-day prescription at the 85% mark would result in 13 extra daily doses each time.
Zielinski noted that his automatic refills included only prescriptions that are covered by his drug plan without any copay, so he doesn’t have a strong financial motivation to slow the shipments.
Nevertheless, the waste got to him last year, and he logged on to a UnitedHealth website and attempted to pause the refills. He said he couldn’t figure out how to do so without canceling the orders altogether.
The company said members can adjust refills through its app, web portal or by calling customer service.
Zielinski said UnitedHealth’s pharmacy arm also sent him excessive supplies of a once-a-month tablet to increase bone density and an inhaler that he uses only occasionally to relieve symptoms of a lung disease.
UnitedHealth said it shipped those drugs according to his medical providers’ orders.
Zielinski said he currently has more than six months’ worth of the bone tablets and “probably a 10-year supply” of inhalers.
