🔒Health insurer ‘white bagging’ policies raise concerns among providers, state officials

When the Connecticut Prescription Drug Task Force released its 15-page final report in February, most readers likely glossed over a short paragraph tucked away on the final page. But for hospitals, insurers and regulators, those few lines — addressing the regulation of white and brown bagging, or the lack thereof — signaled an unresolved and potentially contentious debate. The paragraph reads: “White bagging (when insurers require prescribed medications to be purchased through specific, and sometimes affiliated, specialty pharmacies) and brown bagging (requiring patients to transport specialty medications to their providers) remain contentious, with no consensus on regulation.” Since that report was released, however, the issue of white bagging has become more urgent, at least for those covered by a fully-insured commercial health plan from Aetna. The Hartford-based health insurer, owned by CVS Health, announced in June it was making changes to its commercial medical drug plan lists, effective July 1. The changes included reclassifying five specialty medications to “pharmacy-only” coverage. That means these patient-specific drugs that providers typically purchase from wholesalers and later bill insurers for (a model known as “buy and bill”) could now be supplied only by Aetna-contracted third-party specialty pharmacies — such as CVS Specialty — which would ship them directly to healthcare providers to be administered to patients. The term “white bagging” comes from the fact that specialty pharmacies ship the medications in white bags. The five medications reclassified by Aetna — Remicade, Tezspire, Xolair, Ocrevus and Evenity — are infusion therapies, administered directly into the bloodstream for patients with chronic diseases. That explains why the change got the attention of the Washington, D.C.-based Infusion Providers Alliance (IPA) and its members, which operate nearly 1,000 privately owned, independent infusion centers in 43 states, including 15 in Connecticut. The organization sent a letter, signed by IPA Executive Director Elliott Warren, asking Aetna’s policy review committee to “immediately rescind” the change, saying it’s “not financially sustainable for community-based providers.” The IPA is not the only observer to raise concerns about the change. A national independent infusion center company with four Connecticut locations, a state legislator and the state healthcare advocate also question the decision. They cite concerns about efficiency, access, safety and cost, stating that while the insurer may save money, the expense for patients will increase along with the potential risks. Aetna/CVS Health, though, defends its decision, with a spokesperson saying the insurer “implemented this change with careful consideration for the needs of our members.” The change comes as insurers, healthcare providers and others continue to cite rising prescription drug costs as a major driver of overall healthcare spending. In fact, insurers say prescription drug costs are a key driver of the double-digit rate hikes they’ve recently proposed for 2026 individual and small group health plans in Connecticut.

Who saves, who pays?

While Aetna/CVS Health declined an interview request from Hartford Business Journal, they did agree to answer questions via email. In his emailed response, Phillip Blando, executive director of external affairs for CVS Caremark and Aetna, replied that the health insurer “has changed the way we manage five specialty drugs for commercial fully insured health plans and a narrow set of commercial self-insured health plans.” Members now must purchase the five specialty medications from “any specialty pharmacy that participates in their health plan network,” he stated, adding that the change “allows us to better control the cost of the drugs and keep premiums more affordable, while still providing members with safe, convenient access to these drugs.” However, a study published in the Journal of the American Medical Association (JAMA) in September 2023 found that patients ultimately pay more for white bagging. According to the study, white bagging saved an insurer 14% on the median cost of a medication per patient per month, but the median out-of-pocket monthly payment per patient jumped from zero to $93.60. Warren, the IPA executive director, said the change is significant for the people it affects. Patients treated at infusion centers have a variety of “complex and chronic conditions,” he said. “Think rheumatoid arthritis, Crohn’s disease, MS, severe asthma, a number of chronic and complex conditions. Many of these patients, unfortunately, are living with these conditions for the rest of their life.” Patients receive regularly scheduled treatments, and the infusion process takes time. As an example, Warren cited the MS drug Ocrevus, for which the treatment can last three to five hours, he said. Infusion centers provide patients a way to receive treatment in a convenient location that allows them to maintain “their dignity and their privacy,” and their quality of life, Warren said. For Aetna/CVS Health patients, the recent change threatens to disrupt their treatment, he said, because many infusion centers and hospitals refuse to accept white bagging mandates. “So, you’re creating a patient access challenge, especially in rural areas, where a location can no longer accept patients because of this white bag mandate,” he said.

Process ‘inflexibility’

Woody Baum, CEO of Local Infusion — which has 31 infusion centers in eight states, including four in Connecticut — says the white bag mandate creates additional risks for patients. The buy-and-bill model is “logistically a lot easier for the patient,” he said, because there is no middle man involved in securing the medication. “A lot of these specialty pharmacies, in part because they’re payer mandated, they don’t have great customer service,” Baum said. “There’s often a lot of delivery issues, logistical issues. … So, when you introduce a third party into that process, it just often leads to delays in care.” In addition, he said, if a patient decides to seek treatment elsewhere because of a delayed drug shipment, his centers are not allowed to use the white bag medication on someone else. “It just adds a lot of inflexibility to the process, and that’s a lot of waste and financial risk to the system as well,” Baum said. Kathleen Holt, the state healthcare advocate, says there are other risks as well. White bagging damages the integrity of the supply chain, she said, “because you can’t trace and verify where these drugs are coming from in a way that you can when you have more control over them.” She also noted that a patient’s condition can change between the time a drug is ordered and the time it arrives. With buy and bill, a doctor can adjust using medications in his inventory. With white bagging, the medication is no longer suitable when it arrives, delaying care. “It all goes back to this fragmented, rather selfish way of insurers choosing their own processes over the safety and other protocols that providers have put in place,” Holt said. In his emailed response to questions about this, Blando said Aetna/CVS Health has “more than 50 specialty pharmacies” in Connecticut, including almost 40 “non-affiliated specialty pharmacies” that can be used to fill prescriptions for the five drugs. “These specialty pharmacies have the experience and capability to deliver drugs in a timely and reliable manner to promote ease of access for members and providers,” Blando states. “They will work with providers and members to ship medications according to ‘needs by’ date for patient appointments.” He added that each of the five drugs “has at least one alternative available as a medical benefit, so providers have the option of prescribing a drug that could be purchased from them.” Warren, of the IPA, said 10 states have passed laws either limiting or banning white bagging mandates. Sen. Matt Lesser (D-Middletown), a member of the state Prescription Drug Task Force, said he agrees that the General Assembly and the task force should address the issue in the future. He noted lawmakers did pass legislation during the 2025 session to address prescription drug prices, but it did not address white bagging. “The bipartisan drug task force has been really successful this year, and I think we are going to keep going,” he said. “We have a lot of additional problems to address.”