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By Martine G. Brousse
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Over the past handful of years, there’s been a disturbing trend on how insurance companies manage infused or injected medications, and your doctor may now be forced to obtain them from a mail-order pharmacy.The move, aimed at saving costs (theirs, not yours!), can include inexpensive injections, complex chemotherapy infusions and anything in between.
The American Medical Association and various organizations have decried this move, saying it raises serious concerns about safety, treatment access and liability.
1. The trend
Insurers are shifting the financial burden of many infused or injected medications to patients. Until recently, the medications were purchased by the medical practice where treatments were rendered, and billed under the medical portion of the policy. The medications were purchased from reputable vendors, and they were shipped under proper conditions, guaranteeing safety.
Now, more medical offices must obtain drugs through designated mail-order companies under the pharmacy benefits of a policy. The medications are shipped to the office, called “white-bagging,” or to patients, which is called “brown-bagging,” since patients then have to deliver them to the medical office.
2. What’s the big deal?
There are many unsettling aspects to this business model.
- Administrative hurdles: Offices must request two authorizations — for the treatment (medical utilization management unit) and for the drugs (pharmacy authorization unit). This creates delays and an added burden.
- Pay up now! Before a shipment is sent out, the mail order pharmacy requires the approval and full copay remittance from the patient: no monthly payments or bills after the fact as you would find at doctor’s office.
- Uncertain scheduling: Your next treatment becomes dependent on a delivery, not an established schedule. Coordinating ordering, receipt and administration may test the staff’s (and your) patience. And shipments delivered while you aren’t home can be stolen.
- Provenance: This is a big issue with the AMA, since the origin of drugs cannot be traced further back than the mail-order company. Where, when and from whom were the drugs purchased? The office may end up using drugs manufactured abroad or not inspected in the U.S.
- Shortages: Certain drugs of limited or focused use are often in short supply. Offices “stockpile” whenever possible or purchase expensive alternatives to avoid delaying or canceling treatments. Mail order pharmacies may take longer to fill backorders.
- Labeling: Even if you have no such limitations, your own treatment may involve drugs meant for another patient, but given to you for scheduling purposes or because of improper labeling. Many offices store similar drugs (office-bought and insurance-delivered) together, administering them as needed, not “as assigned.”
- Safety: A box full of sensitive drugs sitting outside for hours may result in compromised contents, or your refrigerator might be too cold or not cold enough. Did you leave the package in your car while running errands? Was it handled appropriately and safely at all times?
- Liability: Is your doctor legally responsible for any product injected into you even when he has lost control of the process? Will his malpractice insurance cover such claims? Whose fault is it in the case of a negative outcome?
- Costs: You may have to pay additional fees for the pharmacy products. Your share of cost might be higher, especially for brand names, and reimbursed at the lowest level.
3. What can you do?
Appeals can be filed, and in case of a negative response, you may request a review by an outside medical doctor.
If expected to handle very sensitive drugs, such as chemotherapy agents, without training or proper knowledge, your health and safety could be negatively affected. Ask your insurance if shipments can be sent directly to the office, which is better than a home delivery. You could try threatening to hold your insurance liable.
The medical office may also request a waiver because of specific circumstances. Drug manufacturers can often help in this process, so might contact your HR department.
In some cases, paying cash might be the way to go. A vitamin B-12 injection, for example, cost less than $1. Offering to pay the office directly will save time and staff hours and should be accepted by the grateful staff.
Be proactive when your doctor prescribes an infusion or injection. Call your insurance to find out every detail, and if the office can use its own stock.
Talk to the medical office staff about authorization guidelines, and if brown- or white-bagging delivery will be accepted. Many offices don’t allow such delivery, citing legal liability and malpractice insurance constraints. If so, an alternative arrangement for home or infusion center administration may be needed.