By Evereth Woodruff 
When my patients come to see me, they’re often managing complex autoimmune and musculoskeletal conditions that cause inflammation, fatigue and a lot of pain. That said, one of the most rewarding aspects of being a rheumatologist is providing new and innovative medications that prevent further disease progression, manage inflammation, alleviate pain, and, most importantly, allow my patients to get their lives back.
However, many of these treatment options need to be administered under careful medical supervision, as they require precise dosing and special handling, or are given intravenously. Given these requirements, practices will often keep these medications on hand and have them conveniently available to administer to patients during their regular in-office visits. With an on-site drug inventory, rheumatologists can tailor treatments, ensure the integrity of the drug, and support better medication adherence for patients.
Unfortunately, in recent years, there has been a growing trend among insurers and pharmacy benefit managers (PBMs) to shift how certain physician-administered medications are covered. Instead of covering these drugs under a patient’s medical benefit – which has long been the status quo – insurers and their PBMs are instead covering these drugs under the patient’s pharmacy benefit. While this might seem like a simple administrative adjustment, it fundamentally changes how practices obtain and deliver essential therapies.
When treated as a medical benefit, practices can purchase medications in bulk, store them securely on-site, and administer them during office visits. This “buy and bill” approach is efficient for both providers and patients. But when a drug is moved to pharmacy-only coverage, practices are required to use a specialty pharmacy to obtain the drug – a process known as “white bagging.” That means each patient’s medication must be ordered individually, coordinated with external parties, tracked for delivery, and stored separately.
This change not only creates significant uncompensated administrative burden and scheduling challenges for providers, but it also delays or limits access to necessary medication for patients. Delaying a treatment that manages flare-ups or promotes bone density while reducing the risk of fractures just puts patient health in jeopardy. But that’s precisely what some of these insurer policies will do.
These policies also pose potential safety concerns, as rheumatologists can’t trace the drug through the shipment process. Further, once a white-bagged drug arrives, it can only be used by that specific patient. If a dose needs to be adjusted based on a patient’s side effects or disease progression, the delivered medication must be thrown out and re-ordered, generating an enormous amount of drug waste.
Payers argue that white bagging policies allow them to pay less for the same drug and limit healthcare costs, but we know this inefficient process drives up costs for patients, who often end up paying more in co-insurance.
All the while, white bagging threatens the sustainability of physician practices, which, if paid under a patient’s medical benefit, would be accurately reimbursed for the infrastructure necessary to deliver care, including trained staff, specialized storage equipment, and the clinical oversight required to administer these therapies safely.
As a nation, we must ask: Should health insurers be working to improve care or create new obstacles?
While solutions to manage rising health care costs are important, they must not come at the expense of access, continuity, or quality. I hope insurers, regulators, and other stakeholders will work to find a better path forward. One that supports sustainable care models, reduces unnecessary burdens, and ultimately puts patients first. When PBMs dictate how and where medications are delivered, it’s not efficiency—it’s interference, and patients are the ones left at risk.
Source: weiyi zhu, Getty Images
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