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Amazon buys PillPack, an online pharmacy, for just under $1B (techcrunch.com)
576 points by dogichow 8 months ago | hide | past | web | favorite | 318 comments

Meanwhile, CVS + Walgreens lost $6B in market cap on the news Amazon is moving directly into pharmacy space.

It's crazy how competitive Wall Street views Amazon moving into a market; have there been examples of Amazon making a large purchase/move but completely failing? (sure there are, just not coming me off the top of my head)

All the time.

They tried to make a move into retail registers to compete with Square, and failed. They shuttered Amazon register in 2015: https://bits.blogs.nytimes.com/2015/10/30/amazon-shutting-do...

They tried to take on Etsy with Amazon Handmade which bombed Etsy stock, but Handmade has gone pretty much nowhere, except some re-branding this year.

People just forget Amazon's failed ventures, even fairly high profile ones, because there are so many, and the hits sometimes so large (like AWS).

Quoting myself from April:

> Amazon's ethos of "Announce fast, Release fast, if it fails, oh well" is intentional. From Bezos' point of view, this is actually a feature. In a shareholder letter in 2016, he called Amazon "The best place in the world to fail." He wants lots of teams working on lots of products, and if some of them don't pan out, that's OK. This has lead to a lot of successes, but also a number of small headaches for consumers who use products that are quickly discontinued and (charitably) forgotten.

From a consumer adoption standpoint, the only thing standing in Amazon Register's way was a lack of marketing.

As a merchant, it was amazing. They offered promotional rate of 1.75%, which is basically impossible to beat for any small business.

For context, Square and most "simple pay per swipe" merchant service providers charge 2.75%. If you go out and get a really good deal from a intrchange+ provider, you might be able to get your rate down close to 2%. But Amazon Register got you below that with significantly less hassle, no subscription fees and a $0 equipment cost.

My wife used it at her small business for a year, and during that year I loved getting proposals from other banks and merchant service providers. Many had an offer like, "Let us audit your merchant fees, and if we can't beat them, we'll give you a $200 gift card."

I always gave them the opportunity to try, but with the caveat that there was no way they could beat our current rates, and I wasn't going to take their money when they failed. Mostly, I just never heard back after they realized I wasn't BS'ing about the fees we were paying.

If Amazon Register had been more widely promoted, they could/should have been able to get every credit-card-accepting small business in the country signed up at least for the promotional period. I'd love to see some kind of post-mortem to explain why they didn't.

Was it amazing because of the rate or for other reasons?

The rate seems like it was just imaginary. Their promotion was that Amazon was willing to lose a significant amount of money to gain market share.

My credit card cash back is 2.00%, your 1.75% promotional rate was losing them money.

There were quite a few people taking advantage of this promotional rate. It was a fun time.

It's 2.00% but with caveats. Usually max limit per year or such.

I have 2% through Citi Double Cash (and yes, it really is 2%, not 1.98%). No caps at all.

They also make money on the data.

> They tried to take on Etsy with Amazon Handmade which bombed Etsy stock, but Handmade has gone pretty much nowhere, except some re-branding this year.

Is severely damaging another online vendor really a failure for Amazon? It seems to me at that level, revenue from a venture is not always the only measure of success.

I had wondered that.

Disclaimer, I'm long SQ.

If you're following AMZN, SQ, or PYPL, you probably saw the headlines back in April:

Amazon's Next Mission: Using Alexa to Help You Pay Friends

Firm looks to make voice commands the next wave of commerce

SQ and PYPL took a small dive on this news, even though at face value, its quite silly. Amazon would probably have a much better time trying to buy PayPal for Venmo or Square for Cash App but also to compete in the small-biz transaction field that Amazon tried and gave up on. Building out such a service based on Alexa users is wacky, and there doesn't seem to be a pressing need to let loose your wallet via voice.

Personally, I think it's somewhat unlikely that AMZN would acquire PYPL due to a clash of cultures when it comes to customer service. (Amazon's: Very good. PayPal's: Legendarily evil). This reputation may also be the reason PayPal has kept their own name off of their Venmo acquisition product until very recently. I think there is a very slight chance that AMZN would try to acquire SQ. It would allow them to really break into small-vendor retail where they have failed with homegrown solutions before, and give them instant access to a growing P2P transaction market. Everybody loves to speculate about such acquisitions, though.

...But it would certainly be funny if the only reason Amazon made that press release was to butter up one of those two companies for acquisition, either by decreasing their share value or exerting pressure on them internally to agree to a deal before they face Amazon's competition.

Its hard to discern what they were thinking of. But I feel like you are overthinking it. Having worked at companies of all sizes, many products are often some executives' pet project to make a splash and other execs just let them do what they want if they're not fucking up other shit too much or taking much needed resources away from other things. Many of the failed ventures may just have been a result of that.

I think that's a good counterpoint.

As an aside, Etsy has really more hurt themselves. There is a conversation upthread about counterfeits on Amazon — Etsys problem is the flood of generic Chinese goods on sale as “handmade”.

I'm struggling to find exactly where Amazon Handmade 'bombed' Etsy's stock in the first place. It was originally announced in 2015 and expanded later last year but both times Etsy has had a small single digit percentage sell off and recovered. Today they're back to above their IPO numbers even.

> Is severely damaging another online vendor really a failure for Amazon?

Yes because while Etsy stock dropped by 60% to less than $10 it has recovered back 42 dollars about 3 years later.

I can't recall which book it was, but there was a story about very early Microsoft attempts at pen computing (like mid-90s at the latest). They created some scripted demos that looked great and failed, and another executive said something like "you sure pooched that". The response was "I wasn't trying to score a touchdown. I'm the special teams guy trying to block a kick."

Two additional quotes from Bezos himself:

> "If you double the number of experiments you do per year you’re going to double your inventiveness."

> "If you decide that you’re going to do only the things you know are going to work, you’re going to leave a lot of opportunity on the table."

And who could forget the Fire Phone debacle?

it's not about how big the failure was, it is about how much was learned from it that can be used in the future.

> lots of teams working on lots of products, and if some of them don't pan out, that's OK

Basically the modern tech titan mantra. The only company out of the big 5 that isn't doing this is Apple.

I'm sure Apple does too, the only difference is they test internally and squash them before the public knows about them rather than letting them fail in the marketplace.

Dont forget one of their biggest failures. Fire Phone.

+ I'm wary of Amazon Grocery. We had a bad experience with home delivery 10 years ago and my wife refuses to do it again. For packaged goods and non-perishables it's fine, but with fresh meats and produce it's hit and miss.

It may not be failure but I doubt it will kill or disrupt the grocery business.

Amazon Fresh - I was really down on the idea, but they do a decent job - better than the alternatives in my limited experience with them.

Items are well packed but not excessively (Google Express once sent me a bubble-wrapped bottle in a giant box for when I just ordered peanut butter - talk about waste).

Frozen items have cooling packs that are reusable and recyclable (pure ice + plastic skin) - and (this was actually useful) frozen drinking water bottles (useful packaging!)

The quality of the groceries were good. Unlike Safeway where sometimes I got what looked like older veggies.

My (more extensive) experiences with both Google Express and Safeway were inferior in little ways. I want to hate Amazon, but they're doing great for grocery delivery.

I'm pretty sure their grocery business has changed alot in the last 10 years, and will probably change even more with the integration of Whole Foods.

Groceries online make me very happy. I'm a convert. Carts queues and parking are anachronisms.

There won't be wide adoption until the customer gets a perfect order with no substitutions or blemishes every time. The psychology of perceived loss at not getting EXACTLY what was ordered is too great. Until then millions of disappointed people will discourage others.

Carts queues and parking still happen, they're just being hidden from you.

Only with services like Instacart where they literally pay people to go and do your shopping for you. Real, end-to-end grocery services like FreshDirect do not.

Even then, there are trucks that park somewhere and containers of grocery product queueing up to be loaded into them...

I never used Grocery, but used Amazon Fresh a few times in recent months. The experience was awful and after 3 orders I went back to just going to a store. Amazon clearly pays their last mile delivery people way under market and it shows. Rude, unprofessional, late and then harass you until you until you fork over a cash tip high enough to make it worth their effort. They also have a strange hangup about getting the bags back--one guy just kept the cooler bags in his van and handed me a stack of half melted frozen chicken, on another delivery my items were just left in the vestibule of my building, again not in a cooler bag.

This is pretty much exactly what I would do if I was at a job where: 1) I didn't care at all and it was temporary 2) I'm also getting paid nothing to do it. So I can't really fault the delivery people in this situation.

The TL;DR is that there is just no margin when it comes to food. Grocery, restaurants, meal kits, etc. People keep trying to deliver these experiences to your home, and having spent 5 years cooking in a restaurant and my entire childhood growing up on a farm I've reached the conclusion that it can't be done. Once you add in the cost of human labor for physical delivery, the margins go from slim to negative.

> People keep trying to deliver these experiences to your home, and having spent 5 years cooking in a restaurant and my entire childhood growing up on a farm I've reached the conclusion that it can't be done.

I think you (and I) might be in the minority here and not their intended market. I don't know anyone with experience cooking who would prefer any meal or grocery delivery services over just doing it themselves. They're probably only focused on the market whose only previous alternative is instant/frozen meals or takeout.

To us: Shitty delivery + mediocre quality = Net negative

To their intended market: Delivery on par with take out + quality that's better than take out = Net positive

Maybe, at this stage, Grocery pickup is The right thing to build.

A very convenient experience, and it gets a lot of people doing the order online.

Once you have that, and if you can convince people to get their orders at a fixed weekly window, you get delivery density, which is key at lowering shipping costs.

And as far making delivery times convenient in this method - you need to loan your customers a passively chilled box they can put on their porch, so they can pick the deliveries when they come home.

Maybe Amazon could have done this while skipping pickup. But since it's less convenient , it's hard to convince people to pay more, and maybe competitors are cheaper.

But going straight away to on-demand deliveries, with 2 hour delivery time? Sure, that's crazy.

They tried a travel site once; they tried to sell insurance once; they tried to make a phone once; etc.

They fail a lot of the time, but sometimes even when they do, it's a kick in the ass to some of the other competitors in the field, which causes them to depress their margins. So sometimes, even if Amazon's presence in the market fizzles out, they end up still reducing other's prospects.

No different than when Garmin's stock collapsed when Google announced free Maps/Navigation [1][2]. It's just the market reacting to supply and demand.

[1] http://www.macnn.com/articles/09/10/28/google.maps.helps.gps...

[2] http://www.businessinsider.com/googles-free-gps-service-crus...

And caused a sea change for the industry and Garmin's business model.

Garmin's automotive segment revenue has dropped from $2.5-billion in 2008, to $700-million in 2017. [1]

They've been able to largely make up for it with revenue from other sources, [2] (mostly outdoor/fitness) [3], but I'm sure that shift and innovation was driven by the event you mentioned.



[3] https://www.statista.com/statistics/217905/revenue-distribut...

Wow those are staggering numbers! Props to Garmin for surviving a 60% reduction in revenue... I would've expected the company to just fold after that kind of loss.

And most of that revenue surprises me. My car has a Garmin system built in (Honda). I never use it. I just connect my smartphone with CarPlay and use Waze (which will be even easier in September when it will show on the main touchscreen).

So in my case, I paid money to Honda who in turn paid it to Garmin for something I'll never use, just so they can say it "comes with Navigation".

I wonder how long that will last before no one cares if a car comes with navigation.

I've already seen high end cars being sold without navigation, and just marketed as "smartphone ready". I suspect in a few years either all the cars will be sold that way, or they will all be self driving and get their navigation elsewhere.

You won't see that until "smartphone ready" means a box truck can tell your phone it's 12ft tall and to please not send it down any roads with under-height structures less than that.

Automakers want to control the quality of the user experience. They can do that better by partnering with a company that specializes in that sort of thing.

They invested $175M in LivingSocial, rebranded it "Amazon Local", then killed it off.

Amazon owned part of LivingSocial and also operated Amazon Local. LivingSocial eventually sold to Groupon.

Ah thanks for the correction

1999 Amazon when after Ebay with Amazon Auctions, about the same time Amazon zShops (now Marketplace) started. Back then a big bet in terms of money and resources that failed.


The target market is dominated by seniors, who no longer have to drive to a local pharmacy and hang around the store while waiting for the subscription to be fulfilled. I am frankly surprised no dominant online player has emerged yet. Perhaps the shipping costs were a constraint?

Actual shipping costs aside, being a delivery channel is way harder for drugs than for most other things.

Amazon is reliable, sure, but what do they have - 99.9% fulfillment, 99% on time, 99% with authentic products, 97% of listed products in stock? Those are guesses, but apply those numbers to delivering vital daily medicines and the problem becomes pretty obvious.

Keeping in-stock rates high and "on time with authentic products" rates near 100% is not an easy task. It's not something pharmacies do perfectly either, but their shortages are generally at a store level rather than national, and they're not asking people to completely switch delivery mechanism to trust a space with online one provider.

I agree in general, reliability is very important. But the reliability is not 100%, even in traditional pharmacy chains, at least from my experience(not for heart medication, though). And maybe, being an online subscription service(i.e. central warehousing and knowing orders in advance - predictability ) makes it easier, cheaper to guarantee that reliability ? maybe even with some errors in the system ?

You can today get a lot of prescriptions mailed to your home just from the local pharmacy like CVS so that's not going to be such a huge advantage. Also pharmacists can have pretty important roles educating people about harmful interactions and answering questions which is something where an online prescription fulfillment service might have a hard time.

True, maybe shipping was a constraint. can any random guy ship drugs ? isn't some special supply chain required ?

Another guess is that changing habits(especially since buying drugs is an infrequent event, and that we're dealing with seniors) and creating trust we're other reasons.

PillPack is basically a supply chain company - it's not an easy field to get into. I don't know if "who can ship these" is a big hurdle, though. Possibly a bigger issue is "doctors and patients are used to calling prescriptions in to pharmacies".

But the main issue with drug delivery is the need for reliability; you can't have somebody's heart medication ship out late or get lost in transit, basically ever. And if you change offerings or go out of stock on specific products (which most retailers do often), you'll quickly be seen as an unreliable way to get any kind of regular medication.

Plus, you can't let any fakes or low-quality products into your supply chain - so sourcing new suppliers is hard, but running out of suppliers for any single product is a crisis.

So being an online seller for use-as-needed prescription meds might be easy, but the bulk of the money is in people taking drugs daily, and that stuff is damned hard to offer.

At a previous employer, I attended a briefing for our health insurance switching to a mail order pharmacy. Granted this was years ago but the amount of confusion and frustration around the signup process, scheduling, skepticism about delivery times/reliability, etc were numerous. To me, it couldn't have been an easier process. For some people (especially retirees), going to the local pharmacy is part of a regular routine that is not seen as a inconvenience at all.

Basically, the largest potential market for you is not tech savvy at all and makes it hard to convert.

I don’t get many prescriptions so when my doc writes one I don’t care who fills it. She couldn’t send it to a random mail order pharmacy, I had to pick one.

I think there’s a big opportunity for insurers to pick a default mail pharmacy that customers out of. So depending on your insurer, the EMR automatically files with a pharmacy you don’t care about and mails it to you within 24 hours.

My employer-provided insurance is UHC, which has a preferred partner situation with OptumRX, a mailorder pharmacy. They give you better rates on your prescription copay if you use them. The mail turn-around time is not great though. It's good for long-term prescriptions, shitty for short term like antibiotics.

My doctor sends short term stuff to a local pharmacy for me to pick up, and my daily long term pills to Optum, who charges my CC and mails them to me. They take about a week to arrive, but you can set it up so they automatically recur, so you always get your next 90 days before your current pills run out.

> there’s a big opportunity for insurers to pick a default mail pharmacy

Looks like it’s already happening, albeit in an opposite direction, with Aetna acquisition by CVS.

Insurers already do that and also limit how many prescriptions they will cover outside of mail order delivery.

CVS is down 8% right now, Walgreens is down 9%, and Rite Aid is down 10%. Investors are very nervous right now.

Short term voting machine, long term weighting machine

I made a small bet earlier in the year thinking AMZN would buy Rite Aid. ah well.

Seems like in any market where Amazon can reasonably compete with a brick & mortar, Amazon will win... Consider how expensive real estate is these days, especially in urban areas (and how much "millennials" like delivery). It's a solid formula.

It's not just millenials in this case. I am an GenX-er with a wife and two kids. We are planning to switch to a mail order pharmacy (Pill Pack or Costco -- dependent on cost) in the near future. My wife, one of our daughters, and our dog (on a human med) taking regular meds. Even being a 5 minute drive from a brick and mortar pharmacy, and it is still a PIA. None of the scripts are on the same schedule so we make multiple trips. Inevitably, you get in line behind someone with a refill or insurance issue turning a quick pick into a 20 minute wait. A service that syncs up script refill schedules and works with doctors and insurance companies on refills renewals is a massive time saver and stress reducer.

But think about how much it costs to have the item physically delivered. There is no way that Amazon can make money on a $10 item that they need to deliver in a two day time frame.

And they have a large brick & mortar presence with Whole Foods.

this happens all the time. wall street makes money from stocks going up and down, they are designed to react to anything by sending stocks up or down. you can confidently buy some CVS Walgreens stock because I bet that stock is climbing back up within weeks

I'm pretty sure the investors on Wall Street are far more sophisticated than just your "confidence".

Remember the fire phone? Neither does anyone else.

Fire phone. Though I'm not sure if it was a purchase.


What about the environmental impact of the PillPack packaging strategy?


(note: above image is of an already mostly empty PP box, they often come stuffed completely full)


I used PillPack a few years ago, and appreciated the reliable auto-refill (in fact their behavior was borderline insanely aggressive, which was fine by me).

However, the volume of single-use plastic trash created by the way PillPack does packaging was downright excessive, and I felt so guilty about it I deactivated my account. It is less convenient now, but after going back to using typical mail-order and local B&M pharmacies in town the process results in approximately 10-20% of the amount of trash.

See the images linked above as examples of what comes with each shipment - it's a plastic case full of little plastic pouches. There is 1 plastic pouch per dose of medication, and the plastic pouches are wound tightly inside. The volume of single-use plastic adds up rather quickly with PillPack.


Why all the downvotes? "Internet points" are unimportant, but it is curious and unsettling to see information about wasteful high-pollution corporate practices deep-sixed.

There are probably ways to create a cleaner packaging system.

But I'm not sure if the plastic problem (a huge one, and I really love nature) will be solved by individual action.

In practice it would require laws, like the anti plastic bag law reduced demand by 70% in the Netherlands.

Or technology, like a better bio-degradable plastic alternative.

How many pills were you taking daily? The plastic waste of 4-5 pill bottles a month is quite large. But yes it is wasteful, just like the rest of for-profit healthcare.

I agree; The film pouches used by PillPack look to use significantly less plastic than those orange bottles.

i see a lot of comments here of people worrying about counterfeit pills distributed on Amazon. A counterfeit drug in USA is a ticket straight to jail, but a counterfeit mug or yoga mat isn't such a big deal. I wouldn't worry about it so much especially because it's not an open marketplace since Amazon will use Pillback as the distributor

People have some very naive views about how one of the most regulated industries in the world operates. A big pharmacy can't just buy drugs from a random internet source and give it to you based on how many users gave that seller positive feedback. I don't know how they think the pharmaceutical industry works in the US, but the idea that Amazon is going to start selling fake medicine is absurd.

I think what we will see is AmazonBasics Aspirin and stuff like that. They are usually not fake.

This is interesting because Amazon isn't exactly known for supply chain integrity. Who here hasn't received fakes from Amazon? If you rely on a specific medication for your health, is Amazon a brand you trust to deliver it? How long until they start commingling pills and shipping random counterfeit/fake product to users?

Hope it never happens but if they do with pharmaceuticals what they did with everything else they sell, it's only a matter of time before users are physically harmed.

Let's be optimistic though, I hope this helps them finally get their shit together and control the rampant counterfeiting going on right under their nose.

This is a very ill-informed opinion. The supply chain is very strictly regulated for pharmaceutical medications.

Do you really think that Amazon can get their stock medications from just anyone? Do you think there is no oversight on this kind of thing? The DEA doesn't fuck around. They take all of this stuff very seriously.

Commingling medications? Really? In a pharmacy, medications are NEVER allowed to be commingled. If your medication is coming from two different manufacturers, or even the same manufacturer but the pills just look different, the pharmacy must put them in two different bottles to give to you. Stock bottle are not allowed to be mixed together. Ever heard of a recall on medications? That is exactly why. When a recall happens, they need tedious records of where every pill went.

When a prescriptions for a schedule II drug is filled, the pharmacy technician has to count the number of pills being filled twice. Then the pharmacist has to count the number of pills, and then backcount the stock bottle to make sure everything is kosher and no pills are missing.

I understand not everyone knows everything about the pharmaceutical industry, my wife is a pharmacist is the reason I know as much as I do, but to think that there is that little oversight on pharmaceuticals is ludicrous.

Amazon has had drug problems in the past...



Everyone knows pharmacies are highly regulated, however Amazon has somehow managed to flaunt regulations so far without much consequences.

I’ll grant you it is worrying to see that happening, interesting articles I had no idea about. Though I would think now that Amazon is officially getting into the pharmaceutical game, this will bring them under much more scrutiny for this kind of thing in the future.

I could be wrong, as the first article states, Amazon skated by without so much as a warning while bodybuilding.com had to pay fines for selling the same steroids, but I would expect the FDA is able to throw their weight around more with Amazon now by shutting down their official pharmaceutical operation if they continue to make perscription medications available like this on their retail site.

> In a pharmacy, medications are NEVER allowed to be commingled. If your medication is coming from two different manufacturers, or even the same manufacturer but the pills just look different, the pharmacy must put them in two different bottles to give to you

Are there any exceptions allowed? I'm pretty sure I've had a major nationwide pharmacy give me a bottle with pills from two manufacturers in it. It had pills from the first in the bottom of the bottle, then a cotton wad on top of those, and the pills from the second manufacture on top of the cotton ball.

They opened the bottle when I went to pick it up, and pointed out what was going on inside and made sure I understood. They explained that they did not have enough pills in stock from the manufacturer they had used before for that prescription and refills, so filled out the order from a different manufacturer.

Perhaps it does not count as commingling because they divided the bottle into separate champers with a wad of cotton?

Pharmacy is regulated state by state. What they did may be ok in that state, or may be marginally ok. At the least, they didn’t just dump them into the same bottle together.

I don't know why you're getting downvoted. I've had the same thing happen multiple times, also at a certain "major nationwide pharmacy." Interestingly, the smaller/more local pharmacies have never done this.

I can attest to this. I recently got 2 bottles of seemingly identical muscle relaxers, but they were just two diff manufacturers. And they made a point of calling it out so i knew why i got two half filled bottles..

Was also going to mention the same. Amazon will buy directly from the manufacturer.

What always seemed odd to me in such a wasteful society as the US: counting pills. Really? In many countries you get blisters. No counting. I suspect in some European countries it would actually be illegal to do this.

The disadvantage is that there are some leftover pills most of the time. E.g. you need 30 pills and there are only units of 20 available.

In New Zealand, I sometimes receive prescription medication in a generic box full of blister packs, where the last blister pack has been cut down to match the prescribed number of doses. Occasionally I'll get a couple of cut down sheets, presumably using up the leftovers from other people's prescriptions.

> The disadvantage is that there are some leftover pills most of the time. E.g. you need 30 pills and there are only units of 20 available.

This is the exact reason why they count pills. You have a prescription for X pills, you get X pills.

It's been a while since I've had a prescription filled, but I think that in New Zealand it's the same. Most prescription drugs like opiate painkillers or antibiotics are counted and bottled.

Here in India, they'll either cut the blisters to your prescription or give already cut blisters from previous orders.

Yes, but is it worth the trouble?

Also, you may be able to build robots to dispense pills. But have you seen a European automated pharmacy supplier? Everything is automated. They dispense all the blister packs into a small cart that gets delivered to the pharmacy. In the end it does not matter if you supply a pharmacy with 2-20 medicines or a consumer with 1-10.

  Yes, but is it worth the trouble?
The "schedule II drugs" jeherr mentions as being counted twice are things like cocaine, methamphetamine and fentanyl. i.e. drugs that could be readily sold onto the black market.

While cocaine and methamphetamine are schedule II, those are poor examples. I don’t think pharmacies ever carry them, and their medical use is very rare.

Fentanyl is commonly carried in pharmacies but it’s not a commonly prescribed medication. Better examples would be adderall, vyvanse, norco and oxycontin.

I used to work at a mail order pharmacy. Even though a machine counted the pills a pharmacist had to certify every bottle. This amounted to bottles coming down a conveyor and the pharmacist picking each one up, scanning it, and looking at a picture of the pills on a screen to make sure they are the same. I wouldn’t doubt if Amazon would need to do the same were they to use individual pill counts.

It's the much superior way to do it though, in France all estimate say we would save a lot of money by doing this, but with such a strong phamaceutical lobby it just never happens. Same reason why somehow we have homeopathy being reimbursed as if it was a real medicine, Boiron is french !

Clearly the parent commenter didn't intend to imply that the industry is not regulated. I think it was more of a tongue-in-cheek jab at Amazon.

I think it's just generally weird that a shipping and commerce company is taking interest in pharma to begin with. I think it SHOULD make users uncomfortable that a single company is potentially exposed to all these different vertices of user information. They know what you buy, soon they'll know what groceries people buy, what they read, what medicine they take which could in turn reveal metadata like sexual habits or genetic patterns.

It's weird.

Is it weird?

I feel like it's more like Amazon just trying to monopolize everything. There are articles out there talking about getting Amazon-ed. Where Amazon would go in your industry and dominate you out the market. (https://www.forbes.com/sites/jamescahn/2018/04/24/dont-let-y...)

This is just a natural thing or the thing that Amazon does. Their modus operandi.

> what medicine they take which could in turn reveal metadata like sexual habits

They do recommendation system and I believe they sell sex toys so yeah... Alexia knows your kink already.

It's not weird but I think the better question is is this okay for one company to have so much power in so many area. Or at least I believe that's what you are trying to convey.

I guess I meant weird in the moral sense. It's certainly not unusual given their past behavior as a corp.

Sort of depressing, really.

That kind of "innovation" is just what I've come to expect from Amazon.

What part of heavily regulated is hard to understand? The Amazon Marketplace is regulated by Amazon. Pharmaceuticals are regulated by the FDA.

Not just the FDA, but also the DEA and the states Board of Pharmacy.

> When a prescriptions for a schedule II drug is filled, the pharmacy technician has to count the number of pills being filled twice. Then the pharmacist has to count the number of pills, and then backcount the stock bottle to make sure everything is kosher and no pills are missing.

Good grace. What a load of unnecessary bureaucracy.

In the modern world medicines come in pre-counted blister packs where there is zero room for error. Here in America we have to wait around an hour for some dolt to count and then double count the pills.

That's dramatically overblown and incorrect (and rather insulting to trained professionals whom you apparently know nothing about). Many perscription drigs do come in blister packs in the US, but you may not have seen them because it's generally only the ones that are nearly always perscribed in the same amount - a Zithromax Z-Pack for example.

Any other medication coming in blister packs wouldn't change a darned thing, unless you expect pharmacies to carry large quantities of sealed 5,10,15,20 etc etc dose packs. If they didn't, they'd still be breaking the sealed packs up and counting to match the perscribed amount.

Actually, it changes things quite a bit. The pharmacist ends up doing some basic math for each script instead of counting pills. Italy does this pre-counted system and getting a script filled takes seconds instead of dozens of minutes.

It is pretty remarkable how inefficient getting pills from a pharmacist is. The actual dispensing could be easily handled by a glorified vending machine so all the pharmacist would have to do is punch some buttons on a computer instead of having to physically handle anything except dumping packages from the manufacturer in it upon delivery.

Actually, some pharmacies do have counting robots now which count out their most commonly filled prescriptions, like norco. They’re not perfect though.

Who do you complain to when the robot shorts you? Unless most doctors are writing scripts for noncomposite amounts of pills this needs to be simpler. Boxes of 15 can turn into 60, 90, 120, etc.

Very common now. All the pharmacies in my primary health system's offices use these: https://innovat.com/pharmassist-robotx/

Why make a human type it in if the majority of scripts are coming in via E-prescription?

Baby steps...in order for that to work there'd have to be some kind of interoperable API standard adopted by all doctors in pharmacies that the system understands (I am assuming there is not). In an ideal world there'd be basically no humans involved as soon as the doctor prescribes, obviously...

What makes you think an ideal world would involve no humans after the doctor writes a prescription? There’s a very good reason we have pharmacists. Doctors can and do make mistakes, and they may not know every medication that a patient is taking. Somebody has to catch these mistakes and potentially lethal interactions.

Doctors are typically not experts in medications. Specialists probably know a lot about medications pertaining to their specialty, but asking GPs to know so much about a vast array of diseases AND the medications to treat them all, AND all interactions between medications is unreasonable. Doctors education is primarily in diagnosing disease. Pharmacists go to school just as long as doctors do (I think the major difference is pharmacists don’t typically do a residency after they graduate unless they are not planning to work in a community pharmacy), but their entire education is based around medications. Pharmacists are the medication experts. It’s a good thing that we have both looking after the healthcare of patients.

Hence why I said "ideal"...

> This is interesting because Amazon isn't exactly known for supply chain integrity.

The supply chain integrity problems were allowed by Amazon because it benefited their bottom line. If they wanted it perfect, they could have made it perfect.

Remember when the eclipse was happening and they actually did a pretty good job of removing all glasses which weren't safe? They know where integrity counts, and I think when it comes to pharmaceuticals they'll know how to play this game clean. As another user commented: Amazon didn't get this humongous by making silly mistakes like this.

Remember when the eclipse was happening and they actually did a pretty good job of removing all glasses which weren't safe?

They also recalled a number of good units, which only sowed confusion and anger among buyers.


And it turns out some of the counterfeit glasses did get out to to buyers who thought they were purchasing legitimate units.


I tried doing a limited google search for any news about that story that occurred since November of last year and got 0 hits. Did the case die or is it that the media just doesn't care enough for there to be a single update to the story?

There's activity on the case (2:17-cv-2313-PMD) as recently as earlier this month, but you'll need a Lexis or PACER account to dig in and see what's up. But it doesn't look dead. Amazon is going to probably bury the plaintiffs in paperwork.

Probably have to check court records to see if it's still open or closed and what happened.

> They know where integrity counts, and I think when it comes to pharmaceuticals they'll know how to play this game clean. As another user commented: Amazon didn't get this humongous by making silly mistakes like this.

Exploding hoverboard case shows how hard it is to beat Amazon in court



> [T]here were so many cases of fires and explosions that Amazon had halted sales. [...] Fox's case was filled with testimony and evidence illustrating that Amazon execs were concerned about the hoverboards sold on its site. [...] [A]n Amazon vice president said the company had decided to halt sales of hoverboards and send a 'non-alarmist' email to existing customers [...] Fox received the email the next day. It referenced 'recent news reports of safety issues' and offered 'safety tips' for using the product as well as an option to return the device for a refund. There was no use of the word 'fire' or 'explosion.' Fox testified that if Amazon had said that 'they knew what they knew, I certainly would have gotten it out of my house.'

I remember that a lot of people found that Amazon told them their genuine glasses were fake, and a lot of people with obvious fakes weren't told anything. They even managed to screw over some sellers of high-end telescope filters that weren't being counterfeited.

> Remember when the eclipse was happening and they actually did a pretty good job of removing all glasses which weren't safe?

Only after people let them know they were not safe and not within a reasonable timeframe for people to order replacements.

That’s your opinion. I disagree. With the glasses they probably needed lots of filtering by hand. Costed them a lot of money. They were afraid of costly lawsuits. But they don’t have the capacity to do that with every product they sell.

If fake goggles had liability problems wait till they sell a fake medication.

They’ll invest the resources to ensure that doesn’t happen.

Amazon didn’t get big by being stupid.

Invest, or lobby for law changes to protect themselves.

Your point stands.

No, Amazon totally had the ability to separate glasses from different suppliers and keep them apart in the warehouse.

The bogus ones could then have been isolated and recalled, but this is not what happened.

I'd say there are two differences between goggles and medication.

1) Goggles used the existing supply chain. Which, as noted, was designed around the idea that customers would rather have cheaper things from any vendor that things from a specific vendor. Presumably the greenfield / acquired med supply chain is engineered around different desires and regulations.

2) By the time the goggle issue came up, inventory was already in the system. With some presumably co-mingled. I'm just saying I wouldn't want to be the DB analyst who got tasked with untangling that.

It's 'easy' to track eack item by type and source. They chose not to.

I understand the fear, but I don't think fake medicine is as big of an issue as fake market place items.

PillPack already has an established distribution network and prescription delivery licensing in 50 states. I don't know for certain, but I would assume that fake prescription medicine is a much bigger risk and would threaten the operation more than, say, fake batteries.

It's likely they'll integrate on the ecommerce side of things, not on the supply chain side anyhow - the economy of scale that amazon has for shipping will be beneficial.

People don't want to buy legal drugs from their UPS guy.

EDIT: i'm from outside the US, and after reading all the complains about delivery people throwing packages etc, i thought people don't trust delivery guys enough for medicine.

It appears i was wrong.

I mail order my recurring prescription medicines from the hospital pharmacy all the time. No waiting in line and they give me a substantial discount.

What exactly do you mean here?

That you don't feel safe receiving your medicine being delivered last mile from some random UPS guy?

If this is what you mean -- I get my medicine by mail order from CVS. I cannot imagine now having to go to CVS every single month I get my medicine.

In many cases, insurance mandates that you use their contracted mail-order pharmacy when possible. In other cases, they recommend but don't require it since the fees are lower for everyone that way. This is in the USA.

For pills, I would expect they'll use USPS, not UPS. That's how I get my medicine. It comes in a shipping bag instead of a box or rigid envelope.

My partner buys legal drugs from her pharmacy. Half the friggin time, there's some supply problem on the back-end, and she can't get her drugs in time.

Anyone who could fix this problem will get her business in a heartbeat.

Ditto. I detest Walgreens because of its invasive marketing and spamming, but I use it because CVS in my area can't keep even basic meds in stock.

I'll be among the first to switch to AmazonRx.

Yeah, the penalties for selling fake insulin are muuuuuuuuuuuccccccchhh greater for distributors than selling a fake Gucci belt. Also the number of companies with licenses to sell regulated substances is pretty small making it really easy to validate.

Shitty generics are a big problem and the FDA doesn't really care.

I reject specific manufacturers from my CVS and get trusted manufacturers all the time.

Hard to do these days though. Teva is killing off a bunch of generics, Puerto Rico still a mess, weird shortages of common meds, etc. Sometimes I spend an entire day going around the city trying to find the specific generic which I'm used to. And then only get partial fills, etc.

It doesn't have to be fake to cause harm, at least for epilepsy. The filler in the pills can vary by manufacturer.

Yup. Insurance companies like to pretend all generics are the same, but they are not. Getting them to pay for the brand because all of a sudden your pharmacy switches generic brands is almost impossible.

Can you explain what is different about certain generics?

Generics, all of them I'd intuit, seem to be manufactured with the same active ingredients but different 'filler' ingredients that are non-active.

Abruptly changing that filler could very well send an epileptic into a static seizure.

it absolutely is a huge issue, with fines that bite. Google had to settle for +500M after serving ads for fake medicines in the US. I wouldn't be surprised if the primary aim here was to get a bargaining chip for their negotiations for their health care JV (a much bigger market)

The integrity of the pharmaceutical supply chain is controlled by a specific federal law, Title II of the Drug Quality and Security Act of 2013, also known as the Drug Supply Chain Security Act.

The potential liability they would be exposing themselves to if Amazon treated their drug supply chain the way they treat standard 'Fulfilled by Amazon' products would hopefully prevent something like that from ever happening.

Yes, and a part of that is track and trace (aka serialization). Each unit has a unique identifier and must be tracked from manufacturer to patient.[1]

It’s a big infrastructure lift so it’s still being implemented.


The FD&C act imposes strict liability on violations, and criminal prosecutions for mislabeling and adulterating drugs have extended to company officers that were completely unaware of the actions their subordinates had taken.

Amazon isn't stupid: they know _exactly_ where they can play it fast and loose in order to maximize profit and where they must operate under strict regulation. This isn't the former.

I think one issue there however is that nearly anyone can sell through Amazon. I assume (perhaps incorrectly) that to be a pharmacy distributing via Amazon would require some level of licensure well beyond what it takes to sell XBox controllers.

Just as a data point, I don't believe I've gotten a fake from Amazon.

Try buying a PS4/PS3/Xbox controller. There is a good chance it is a good looking fake. Apple accessories are another hit or miss target.

Even if you're buying directly from Amazon, or does this only apply to marketplace sellers?

The problem is that inventory from different sellers is commingled unless the seller pays extra. So Amazon's controllers are in the same bin as the ones from Real Good Fakes Inc. Even if you buy from Amazon the actual product you get might have been supplied by Real Good Fakes.

Is it not still shown as "Fullfilled by Amazon" but all grouped under the same product page? I presumed "Sold by Amazon.com" meant procured, shelved, and shipped directly via Amazon.com, none of this third party fulfillment crap.

It is. The issue is that for the "shelved" step there is only one shelf per piece of inventory. So once it is one the shelf there is no guarantee about the origin.

Amazon does allow sellers to pay extra to keep their inventory separate. I don't know if the stuff Amazon sells is kept that way, but there's no guarantee it is.

I want to know this too. "Fulfilled by Amazon" to me sounds very different than sold by Amazon.

FBA and Sold By Amazon are commingled (unless the FBA seller pays for it not to be; Amazon doesn't segregate SBA because the commingling is part of Amazon's logistical efficiencies, which is why it costs money for sellers to opt out of it.)


That doesn't make sense. They would then need to make sure "Real Good Fakes" products are cheaper than what they send... At anytime "Real Good Fakes" can ask for his stuff back and that has to be "Real Good Fakes" stuff or there may be a big problem (used vs refurbished vs new).

They automate everything, there's no way there's no barcode for this kind of thing.

I can confirm this as someone who used to do 6 figures plus of business on amazon every quarter. Unless I mark that I dont want my inventory commingled (which is an option more expensive than general FBA) once my product shows up at the various warehouses it's dumped into a bin along with everyone else who sent in the same part in for FBA fulfillment.

I got all my product from HP via Synnex, all factory sealed brand new genuine parts. The number of times I got burned by people leaving shitty feedback or returning stuff because what they got when they placed there order for the part I was selling was some knockoff that was close but not exactly it was high enough that I no longer sell on there.

Commingling is certainly something I wasn't aware of, it looks as if most consumers are in the same boat.

The idea that FBA doesn't actually get me parts from the seller I picked has never crossed my mind. I certainly wouldn't have bought quite a few things if I knew that possibility existed.

It's part of their distribution strategy. I'd generally send 500 units to their warehouses a week. When you're dealing with quantities that large they have you split it up to several shipments to different warehouses throughout the country.

Usually it would be many small quantities near me, and then one large one to the other coast which they would then distribute amongst their warehouses on that coast themselves.

So as the number of vendors stocking inventory increases, the cost to amazon to distribute inventory widely enough to hit SLAs goes down because more of the cost is borne by the vendors.

I guess I see how this can happen for everything marked as "New" with no extra details, but how does this work when the ones from different vendors are in a different condition (missing box or whatever)? Are they still commingled then? And if so then how do they make sure the condition matches the one they send you (e.g. not give a missing-box as one that's factory-sealed)?

Used items are not commingled with new items.

But what about with other used items? It's the same problem either way.

And what about "New" items missing packaging etc.?

This isn't an actual problem Amazon has, and Amazon has enough problems that we don't need to make up new ones to discuss. Used items are tracked and sold individually (with their unique condition described and viewable by the purchaser), unlike new items. They're not just binned together by condition, when you buy used you're buying a specific item out of inventory. A "new item missing packaging" would not be sold as a new item. "New" items that are returned to Amazon are re-sold as used under the Amazon Warehouse Deals brand, even if the packaging looks factory sealed, for example.


>At anytime "Real Good Fakes" can ask for his stuff back and that has to be "Real Good Fakes" stuff

no, they can't, and it doesn't have to be. that's how the FBA program works - when you send your stuff to amazon, they store it in their warehouse on the understanding that it's identical to any other example of the product it is listed as. You can't then turn around and say "i want all the ones i shipped you back", because you've told amazon that the products are interchangeable.

This seems like a viable scam opportunity.

Ship in a crate of counterfeit widgets to mix into their fulfillment pool. Price them stupidly high so they don't actually sell.

Wait a few weeks, to let the inventory churn. There's a fair chance some of your items will actually be shipped out, and many more will be so mixed with turnover from real sellers that it will be difficult to trace back to you.

Then pull the listing and ask for "your" inventory back. Odds are, you'll get at least some legitimate products back, which you can then sell elsewhere at a significant discount.

The math for it to be economic is interesting and likely varies on product price versus counterfeit price, and the rate at which inventory turns over.

Amazon is actually happy to charge you more to use FBA to keep your inventory non commingled. So you can totally get all the exact things you sent them, as long as you paid for the ability to do so before sending all your stuff to the warehouse.

> Source?


Shipped and sold by Amazon.com means that the product is shipped and sold by Amazon Retail (via Vendor Central or Vendor Express) directly. Basically, the manufacturer sends product to Amazon.com at a set price through a traditional PO process. This inventory is commingled with all other FBA inventory.


Richard added, "[T]he consumer always thinks the chain is: Manufacturer » Amazon » Me. But the reality is that is pretty much never guaranteed. The only way that's guaranteed is if you find the manufacturer's listing on Amazon.com and buy via [F]ulfilled by Amazon directly from them, AND they happen to choose to opt out of commingled inventory. In every other scenario there's a chance that you get inventory that didn't come from the manufacturer."

This is true of the PS3 controller(same on ebay). I dont know about the PS4 and Xbox

But on ebay, the seller and the shipper are the same (well, actually, a lot of ebay sellers use third parties- even Amazon, to ship, but the seller is still responsible for the product that gets shipped).

This is not a useful data point, because there is a much larger set that this doesn't meaningfully contribute to.

Hacker news comments are hardly a random sample, and yet here we are.

> Just as a data point, I don't believe I've gotten a fake from Amazon.

You almost certainly have, though you may not be able to tell the difference if you don't actively look for it.

This is one of the things that gets missed when people talk about Amazon and fakes. It's not just about the cost of keeping nonfunctional fakes out of the product stream, it's about the higher costs of legitimate products.

Obviously, the USB drive stuffed in an SSD case is a fake. But that's not the only kind of fake going - printing "Seagate" on off-brand disks happens too, probably with much higher frequency. And cracking down on that would not just be harder, it would be a way bigger threat to Amazon's margins.

Hopefully the PillPack supply chain stays separate or separately monitored, but this wouldn't surprise me either - most cheap online pharmacies are selling real medicine at lower margins, possibly with worse quality control.

> You almost certainly have, though you may not be able to tell the difference if you don't actively look for it.

The gp merely asked for anecdotal data, nothing rigorous. By disagreeing, you are indirectly implying that the commenter is somehow incapable of telling fakes from the real deal.

How does anyone reliably tell fakes apart?

In my experience, it's been because the fake one breaks down in just a few days and I end up ordering a new one, after which point I notice the important differences between the two :(

Man, yeah. I’ve stopped buying anything food-related from Amazon, and I’m very hesitant to use it for anything that will come into contact with me or my family. If they integrate PillPack’s supply chain with their own, I would be extremely unlikely to even consider the service.

Have you actually received fake food from amazon?

Food items can end up 2x+ times the price over a grocery store because there are hidden shipping costs. And many times the higher prices cause less people to purchase, so the item has a short experiation date.

And Im concerned about knockoffs as well.

Knockoffs of what food? Like selling not organic produce as organic?

NPR interviewed the author of Real Food, Fake Food. Basically everything is fake, olive oil, fish, Parmesan cheese


That's far from an Amazon problem. Olive oil fraud has been a thing since before Christ.

I used to hear about family members recieving fake ferroro rocher in America many years ago. But here is an recent example in china.


If there was any incentive to create and sell a knock off product, it is only increased when Amazon provides laxadasial environment.

If anyone buys a “ferroro” rocher instead of a “ferrero” rocher I would say that he is asking for a fake...

Looks like a loophole if you place it in small font: "Its not ferrero, its ferroro"

Fake bananas from Honduras?

Likewise! I don't buy anything food related from Amazon and won't buy medicine either.

They have lots of different businesses and associated supply chains, they're not going to have random 3rd parties selling prescriptions on Amazon like they do for many verticals.

There would be no reason to integrate prescriptions in with their warehouses, so I don't think one is going to change the other.


Do they all ready have a supply chain close to the requirements needed in healthcare ? For what ?

They operate data centers for the CIA, I'm sure they can figure out how to get your pills from Pfizer to your front door. Regardless, they just bought a company that already figured this out. The hard part is the nationwide licensing, dealing with insurance and record keeping, not pick and pack.

It depends on what you mean by healthcare. There are many different supply chains in the industry and they are all regulated and managed slightly differently.

Great point. I work in the pharmacy space and most of the cost is meeting regulations. Other than for the most common medications there are regulations for most all drugs. Add to that the complexity of drug delivery (some medications need to be cold, have tight expiration dates etc.,) its very hard to push down the prices like they have done in other areas.

I would love for Amazon to come in and transform this space. There are lot of improvements to be made but all the well established players know those improvements but unless the regulations catch up its hard to innovate.

One thing Amazon might be able to do is to take a hit to their bottom line by essentially selling drugs at a loss and wait it out till they drive everyone out of the market and increase prices. But no one cares when the price of a book/toy increases by x%. Everyone cares when the price of a drug increases by the same amount. (https://www.cnbc.com/2017/04/03/mylan-hit-with-racketeering-...)

There's no way they'll allow third-party sellers or co-mingled inventory, which are the source of the supply chain issues.

There's absolutely zero chance prescription meds will go through the same "just send us stuff and we'll throw them in a big shared bucket" process regular items do.

How would they get the fakes though? This is not a USB stick or a cable to get fakes from China. There are strict laws that control how they are obtained.

Amazon only has a supply chain issue because they allow 3rd party sellers to provide inventory with essentially no oversight.

I'm not sure anyone thinks Amazon will allow 3rd parties to sell prescription medications. Although if they want to let me cash in on my dead mother's extra chemo meds and pain pills, let me know where to sign up.

Maybe this is related to Amazon's health venture? Both it and Pillpack are based in Boston after all.

Possibly, CVS has a program which uses it's big discounts it gets on the drugs it sells in stores to sell them to employees for their health care needs: https://www.benefitnews.com/news/cvs-e-prescription-program-...

Does this really apply to products sold by Amazon?

Absolutely! Some time ago, Amazon began mixing their inventory with FBA (fulfilled by Amazon) inventory. I've purchased books and small electronics from Amazon (sold & shipped by Amazon) that turn out to be counterfeit.

Yeah, I've bought counterfeit Amazon Basics batteries off of Amazon before :/

How? Amazon doesn't allow 3rd parties to sell/list AmazonBasics batteries.

That sounds shocking to me. Did you notify Amazon about that?

I don’t see any reason why Amazon would have difficulty here. There’s already regulation in place and generics are designed to be interchangeable—getting an off brand alternative would be a win to the consumer, so long as the choice is clear.

> There’s already regulation in place and generics are designed to be interchangeable—getting an off brand alternative would be a win to the consumer, so long as the choice is clear.

They're not, though.

As an example, my wife is allergic to a filler ingredient in one generic manufacturer's version of one of her medications.

Isn’t that part of the reason they’re buying a company that has developed strategies for this sort of thing?

Amazon was in negotiations with hospitals for doing their supply chain. That could be good branding.

> the rampant counterfeiting going on right under their nose.

This is news to me. Can you link an article about it?

I'd be more worried about the quality of generic formulations.

Jesus this is hyperbole...pure hyperbole.

Just found out about PillPack, would have given them a shot but I don't feel that I can now.

Yes but wasn't Holmes allowed to give people fake services for many years before it caught up with her?

In no way I say it was fine, I'm just saying that Amazon will have time and opportunities to fix whatever counterfeits popup before hammer will go down on them.

It may also be they won't allow 3rd party markets into healthcare, we just don't know yet all the details.

Just don't buy "VVViagara Including Free Ray Bann Sunglasses" and you should be safe from physical harm. They always get you with the trademark misspelling and bonus gift.

I interviewed at Pillpack years ago and was very impressed but didn't get the gig. They seemed to be solving a great problem for customers using multiple medicines. I am not sure the solution works well for the millions of us taking one pill every night, e.g the "pillpack" is wasteful.

It also doesn't address this really annoying problem I have getting my daughter's ADD meds. These require a paper prescription that must be hand couriered to the local CVS. A giant PITA.

That’s weird... I live in NYC and get my Vyvanse prescription delivered by Capsule. Haven’t had to drop off a paper prescription in years. Different local laws? Or maybe it’s because she’s a minor? That sounds frustrating, sorry you have to deal with that.

P.S. While we’re on the topic, if anyone’s interested in a libertarian perspective, check out Jessica Flanigan’s 2012 JME paper “Three arguments against prescription requirements”: https://jme.bmj.com/content/38/10/579

Likely it's due to the Controlled Substances Act - one of the most common ADHD medications, Adderall, is schedule 2 or schedule 3. Electronic prescribing for controlled substances (EPCS) has strict requirements and your local pharmacy or your physician may not yet be certified.

Right, but Vyvanse (lisdexamfetamine) is also a Schedule II ADHD medication, hence my surprise that this person has to jump through more hoops than I do. You have a point about certification, though... perhaps less populous areas don’t have these advanced systems in place.

hmm, that's really interesting. She's on Vyvanse. I'm in MA.

With a few exceptions, paper prescriptions have been outlawed in New York State. Everything is electronic now.

Finally. No more important artifact that can be lost, forged, or written on with horrible handwriting. Phoning home to a database is much harder to fake than a paper document with security features like watermark, hologram, microprinting, etc. Is this even for schedule II meds?

As a bonus, the pharmacy team usually has the meds ready by the time I arrive instead of needing to make a second visit or waiting after handing off the slip.

Similar story here, met them circa 2014/5. Their top target audience is seniors and elderly with several medications at different times of day. The baby-boomer generation will be around for a long time to support these kinds of Rx delivery mechanisms. I expect the other existing Rx delivery companies in the space to start doing daily-packs style in the future.

> They seemed to be solving a great problem for customers using multiple medicines.

Most high-street pharmacies in the UK have offered pill-packs for years; you route all your prescriptions to them and their pharmacists arrange the medication into little time-inscribed compartments on a blisterpack.

For them there is benefit in monopolising the medicines of each customer ( more $$ from the NHS ) and for the customer it becomes simple to take medicine at the correct times and intervals. For relatives it's also simple to check that medicines have been taken as required.

PillPack seems to do that, but 'on the Internet'. shrug

>Most high-street pharmacies in the UK

>PillPack seems to do that, but 'on the Internet'. shrug

Leaving aside the fact that 'on the internet' is a huge and important distinction (you should check out this company Uber, it's like a taxi but 'on the internet'), you seem to be saying "there's this great service available to us here in the UK, I can't imagine why a company in the US would want to replicate it shrug."

I'm curious if you know why the ADD meds must be hand-delivered when government is actively incentivising e-prescribing among providers?

Controlled substance and cannot be prescribed more than 1mo supply at a time.

I get a prescription for a 3 month supply of Vyvanse (amphetamine), 90 pills.

The real pain is in the pharmacies who love to power trip. The CVS near me got a new pharmacist who decided she didn't want to fill my prescription because I wanted to pay in cash (no insurance at the time). Didn't even offer to call up my doctor's office to confirm. Just a hard no and goodbye. Made me feel awful, like I was trying to cheat the system or something by paying the ridiculous retail price of $850 for a drug that cost me $20 when I had insurance.

Had to go across the road to Walgreens who never let me down.

What a hilariously stupid system we have making everyone feel like a criminal. I get anxiety all day when it's time to refill. A drug I've been taking for 10 years.

To get what you want, you must first understand the perspective of others. Understand their motivations and incentives and then take the path of least resistance. Apparently pharmacists can be held personally liable for narcotic law violations. When you pay in cash instead of with an insurance claim you are not in the system. Not all cash payers are trouble, but a noticeably higher proportion of cash payers are trouble. The same goes for being a new patient/customer, saying you lost your bottle, or needing an early refill. Assholes who re-sell their methylphenidate are why DEA, docs, pharmacies, etc. are putting up barriers.

As you noted this can be hostile to the people who need to take their meds. You can get stuck in a vicious cycle where being in urgent need is interpreted as suspicious which leads to denials and lack of meds makes you more harried. It's worst for people who are physically dependent on their meds and will who go into withdrawl, pain, or become very unproductive.

I've had similar experiences to OP, and I can also attest to the fact that it is absolutely obnoxious to be treated like a criminal in the normal course of filling your daily prescription.

Sometimes you have to travel for work, and because methylphenidate is such a threat to society (it isn't) you can't fill prescriptions out of state. So you talk to your doctor to get a special prescription with written instructions to allow it to be filled 4 days early (gasp!) so you can fill it before your trip. The pharmacist then rejects filling it for you, for reasons they refuse to explain.

I see a doctor in my home state, about an hour's drive from where I currently live. I see this doctor once every three months. I've seen him for 10 years. I would like to continue to see him. Recently I was put on a light sleep aid for anxiety reasons, I went to fill this prescription (which I have to do in the state that I see the doctor in). I was told my insurance only allows me to get a 2 week supply, and I'll have to come back in 2 weeks later to fill the rest of the 30 day prescription the doctor wrote. When I asked how much it would cost to just pay out of pocket, it was negligable, 20 dollars or so. When I asked to just pay for it myself to avoid making a long trip again 2 weeks later, the pharmacist decided to deny giving me anything.

I thought controlled substances required eprescribing, but they aren’t per the DEA. They are allowed though. [0]

It must just be some health systems require it as policy.

[0] https://www.deadiversion.usdoj.gov/ecomm/e_rx/faq/faq.htm

It is a huge pain. Even if your prescriber gives you 3 prescriptions (1 month each, which I think is the maximum amount of time for a controlled substance in a single prescription), the entity that is fulfilling that order is not allowed to hold onto the other 2 for future fulfillment.

Yeah the doc can put a "do not fill before [date]" and schedule scripts out for three months.

Both CVS and Rite-Aid have an arcane system where controlled prescriptions are kept "offline". Their websites will not show the scripts as available to refill even if the doc has prescribed ahead of time. So one has to call to confirm the script was received, then call every month a refill is needed.

But even worse...Rite-Aid requires a mandatory 30 day wait (per 30 day script). So that means on the day of refill...one needs to rush over early in the morning to get the refill, otherwise will risk missing a dose.

CVS is a little better, allowing a 3-5 day early fill. But they also have their secret "offline" system for controlled substances. It's still a royal pain.

So for Amazon...very little effort is required to succeed...simply show scripts that the doctor has sent over on their website...and offer a 2-5 day early fill....CVS/Rite-Aid won't stand a chance....

> for the millions of us taking one pill every night, e.g the "pillpack" is wasteful.

Does the pillpack have a separate pack for each day with the date clearly labeled? If so I feel that would help a lot with adherence, which in my opinion is a serious problem

It does. The only problem is getting more granular - if you have a medication that is administered throughout a day, you'll have to handle that yourself.

That's not exactly true, if you take medications at different times during the day you'll have multiple packs for a single day marked with the time of day.

Ok, that's an improvement since I was with them, then. Good to know.

I feel for you dads that have to wait in CVS/Walgreens. Hopefully the system gets easier for you guys. Maybe your doctors office could setup eRx but that does require certain software/money.

Congrats to Techstars Boston and the first unicorn exit of a Techstars company! Awesome news

Just an FYI. I measured the inside temp of my mailbox in August’s once and it was 150 degrees. You want to be careful getting medications in the mail.

This already a regular thing - see Medco/expressscripts who will mail you items.

Additionally Pill pack address this on their website for temp. Controlled teams being shipped in a temp controlled way door to door (see Omaha steaks as an example of ‘it’ll be fine)

My employer recently changed up their prescription drug plan and now we're required to get any and all regular 'maintenance drugs' via expressscripts (we're also now limited to using Walgreens for acute/temp medications - apparently dictating which pharmacies you can use is becoming a thing with medical insurance).

ExpressScripts is absolutely terrible. What once was a simple problem: Get a Rx from your doctor, go to any pharmacy and get it filled, has now become a painful process of:

- Call doctor's office, ask them to send the Rx to express scripts.

- Call express scripts, verify they have the Rx.

- Two days before you run out of medication, you get an automated call from Express scripts telling you to call them back.

- Call Express Scripts, wait on hold for 30 minutes.

- Someone finally tells you that there's a problem with the Rx, and you need to call your doctor and have him re-send the Rx specifiying dosages, etc. in a a very specific way. This is Friday afternoon, of course, and your Doctor's office is already closed.

- When you explain you're going to a miss a dose of a medication that is dangerous to stop suddenly, they absolutely do not care ("You'll have it in 5-7 days, once we receive all the info we need", click).

It isn't just me. I overhear a lot of angry phone calls between employees and express scripts in the cube farm at work now. Employees are wasting work-time dealing with something that used to be simple - getting their prescriptions filled. Hope the shareholders are happy.

How do you think the medications get to your local pharmacy?

Via climate controlled aircraft, distribution facilities, and relatively well ventilated delivery trucks?

No step in the retail pharmacy supply chain involves routinely putting it in a small black box sitting out in the sun until you get home from work in the evening.

I’d be utterly shocked if you’re correct. Controlled substances most likely do get some kind of kind of courier delivery, but there’s no reason to do it for anything else. If it needs to stay cold you slap in an insulated box with ice packs. I’ve gotten deliveries before from Blue Apron and Omaha Steaks. Believe me, they have no problem keeping things cold.

You seem to think I'm describing some special courier service. I'm not. I'm describing the standard USPS/UPS/FedEx experience all packages get, which is indeed how most of the stuff a retail pharmacy gets will be shipped.

The parent's concern with direct-to-home delivery is valid - the inside of an in-sun mailbox on a 90 degree day is going to well exceed safe thresholds for many medications in a way the rest of the shipping chain won't.

I can't speak for the others, but UPS definitely doesn't use climate controlled facilities or well ventilated trucks. In particular the semi trailers that transport packages between facilities are saunas in the summer and ice boxes in the winter after hours on the road.

Perhaps in long term Amazon drones with climate controlled container could drop the medicine off.

Or they can just deliver it like they do now without issue.

Pillpack is a very useful service, particularly for people who take multiple medications. You get a little pack with the date printed on it so you never have that "did I take my pills this morning?" question. Their pricing is fine, and delivery is always on-time.

Only problem I've seen is that they often (and I mean OFTEN) forget to apply medication savings cards, which adds up to quite a lot of money. I had to complain about this eight or nine times and ultimately escalated to one of their founders, a guy by the name of Eliot, to get this addressed. However, they may have fixed the problem as they haven't overcharged me so far in 2018.

Prices are set by insurance and shipping is already free so I can't see how Amazon would improve on that. I imagine their margins are razor-thin, but it's pretty clear this sort of service will be how everybody gets their medicine in the next couple of years so the volume makes sense for Amazon.

Just another step in dominance for Amazon. Pretty soon you will be able to upload your prescriptions to Amazon and Prime Now will deliver within an hour, for $8.99


CVS owns the 2nd largest prescription benefit management provider and is purchasing the 5th largest health insurance provider. They will be able to use differing co-pay levels to drive pharmacy business.

Walmart has been negotiating either a purchase or partnership with Humana. This may drive Walmart to be more agressive towards finalizing a deal or maybe even have them looking at a different potential target such as Cigna which has agreed the purchase Express scripts, the largest PBM.

I remember all the way back to when Merck spun out Merck Medco, which Express Scripts acquired (by that time, renamed Medco Health Solutions) to become the largest. Amazon is a guppy in an ocean with this acquisition. And yet Bezos owns WaPo, which is the basis for my statement.

How has this not been a thing since Reaganomics became standard policy for the last 6 administrations?

I think he is specifically calling out the "tweeting" portion. IE, yes, companies have been lobbying to block their competitors for a while, but it's a fairly recent trend that all you have to do now is tell Trump he's the best and he will put out a twitter hit campaign against your competitors

Oh, My misunderstanding, then =). Fair enough I guess. I guess access to the President is cheaper now, through technology. Yay?

So now I have to worry about counterfeit pills showing up from Amazon?

I’m not overly concerned about their dominance anymore. There are eventually going to be regulated.

A marketplace and something like pharmacy are completely different. They will still get their drugs from known producers, and on the generics side you'd have things like teva.

I can already get my pharmacy prescriptions from mail order fulfillment houses (up to 90 day supplies even depending on the prescription). What does Amazon offer on top of that? I’ve never not been within 15-20 minutes of a Walgreens or CVS when I needed a prescription immediately, so I don’t see what benefit Amazon brings to this.

They’re (Amazon) not faster, I don’t care if they’re cheaper (insurance coverage), and I don’t trust them (supply chain, motivations, etc).

Well, you're saving the 15-20 minute drive each way (assuming they're not on your way already) and the hassle of talking to someone online.

Remember, AMZN is entering the health insurance space as well, so that vertical integration can remove the "is this covered?" question that some with substandard insurance may have.

And with regards to supply chain issues, there's no reason for Amazon to open up their pharmacy service to third party sellers. Yes, they'll get a larger selection faster, but isn't that what this acquisition is for?

Pillpack sends you a roll of pills every month packaged in little plastic pouches. If you take multiple pills a day it can simplify your regimen.

Pillpack works proactively with your doc and insurance to handle refills, paperwork, etc -- more so than any other pharmacist I've had.

To your point, you aren't Amazon's customer, the insurance companies are. They might be able to use their size as leverage for better prices from manufacturers and compensation from insurance companies. There may also be synergies with Amazon's business lines because volume is a big factor in fulfillment costs. All of these factors might give them an edge over other online or brick and mortar pharmacies.

I agree it’s probably a great economy model for people who would have it forced on them (Likely Amazon and JPMC workers who will have their insurance provided by their new employer healthcare consortium).

> I can already get my pharmacy prescriptions from mail order fulfillment houses...

Having just spent two weeks calling daily to get my daughter's specialty medication sorted out, I'm all for Amazon's customer service approach entering this space.

When Amazon promises a resolution/callback, I trust it. Express Scripts promised me callbacks not once, not twice, but four separate times without ever making one.

I completely agree. But being adequate-to-worse is in line the rest of their operation, and yet they're widely popular.

Every time I'm subjected to multiple dark patterns simply in the course of checking out (say, for some brand that makes Amazon their official distribution channel), I wonder why so many seem to be singing their praises. I can only think there's just a sizable segment of newly-digital suburban-hipsters, finally discovering online ordering in general and comparing Amazon to say driving to Target.

Let's see.. How do i get started with "mail order fulfilment houses", I don't know. Is there a web site? Do they send fliers?

With amazon it's convenience, and scale. PEople go to amazon.com when they want to buy something (be it vitamins, or electronics, doesn't matter).

This just makes their hands stronger.

> So now I have to worry about counterfeit pills showing up from Amazon?

No, because that would land them straight in jail.

I don’t believe that for one moment. It’d end with a fine and a scapegoat getting fired. Is Elizabeth Holmes in jail?

She’s been charged with fraud, which carries a jail sentence. So most likely, yes.

Nothing medical, just investor fraud.

The way they're going they're going to announce Amazon Government soon, and solve that problem. Talk about cloud feudalism turning into real feudalism.

The UK already has a company that does the government loves to outsource things to: https://www.theguardian.com/business/2013/jul/29/serco-bigge...

So I imagine you'd call about your local trash pickup or a kindergarten and you'd get put in the call center telephone queue.

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