Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Hi, welcome back. And we have Charlie Becker from the Healthcare Advocates Office to testify on H577.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Thank you very much, Chair Black. Just for a sec, can I check-in with you on timing? I mean, I don't want you to cut into a half hour block.

[Rep. Leslie Goldman (Member)]: We Colin

[Rep. Alyssa Black (Chair)]: who's joining us. Yes. Yes. Colin, can you give an idea of approximately how long?

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Ten minutes I can be

[Rep. Alyssa Black (Chair)]: Ten minutes. So you have thirty minutes total.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Okay. All right. Well, you know, I timed myself yesterday and I don't even want to say that that's what it came out to. I'm going shorten it from that because that's a little too long. Right. I'll try.

[Rep. Alyssa Black (Chair)]: We can have you back in next week.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Absolutely, okay. So thank you so much. My name is Charles Becker. I'm a staff attorney with the Office of the Healthcare Advocate. It's great to be here again before this committee and for the new members. Yeah, I think you've already met my boss, Mike Fisher, you've been introduced to our office, the Office of the Healthcare Advocate. So you know that we advocate for affordable and accessible health care for all Vermonters, both on an individual level through our helpline and on a policy level, such as by doing things like this by offering testimony on legislation. And if the topic is prescription drugs, as the chair alluded to, you're most likely to to hear from me. So thank you for the opportunity to speak to you today about H five seventy seven and establishing the Vermont Drug Discount Car Program. I have a brief slide presentation that I prepared for you. Let me get that up on the screen before I really get rolling here. Okay. Is this oh, yes. It is. Great. Perfect. But I have that weird window there. That's okay. All right. So my presentation, just to give you a brief little roadmap, I'm gonna spell out what the HCA believes to be the main benefit of Vermont joining this, our ARX program. I'm also going to discuss a potential drawback to the program, and it's not specific to ArrayRx. It's more in general to discard cards generally. You've already had some discussion about this. It's about whether or not the spending counts towards deductibles and out of pocket maximums. I'm gonna offer a way to potentially strengthen this bill or if you want this bill to be a clean bill, maybe it's in a companion bill, but just a way to ensure that Vermonters truly get the benefit of what this program offers. So I did prepare a slide, my first slide. I'm going to, in the interest of time, breeze through this. What this slide does is it compares and contrasts copay cards with discount cards. Couple of years ago, I spent a lot of time in here talking about copay cards. The the focus of those discussions was wanting to make sure those copay cards counted towards deductibles and out of pocket maximums, and indeed, you all ended up passing legislation that said those co pay cards have to count. There's a difference. Co pay cards and discount cards are not the same thing. Co pay cards work with insurance. And you've heard ample testimony this morning that discount cards, generally, you have to choose. Do I use my insurance or do I use the discount card? And so in effect, using a discount card bypasses your insurance. And it's for that reason, there's this question. Does this discount card spending count towards deductibles and out of pocket maximum? And that's the key takeaway I wanted you all to have from this slide in particular. Before I advance the slide, I just wanted to say, we do support five seventy seven. We support giving the treasurer the authority to bring Vermont into this multi state drug discount card program supported by ArrayRx. A drug discount card is not going to be the right solution for every Vermonter. You heard that already. Even though every Vermonter would be able to use the card, not everyone would want to. And I'm thinking here about people on Medicaid with those very low co pays or people on those newly extended MSPs that you all worked on last year. Those people are not gonna wanna use these cards. Some Vermonters are already well protected from high drug prices, and this program won't be for them. But for the people who do not have those protections, maybe they're uninsured or they're underinsured or maybe their prescription drug coverage is terrible or just even not so great, Vermont Drug Discount Card program could help those Vermonters, myself included, and I'll run through a real world example here in a few minutes. So now let me go ahead. Here's this, I asked Chittenden to create some art for me. An original work of art by Chittenden.

[Rep. Alyssa Black (Chair)]: That's so

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: cool. And I thought I'd start with a lighthearted illustration of what I think the value of this program is to Vermonters. So here we have a slightly perplexed looking diner. That's the prompt that gave Chatuchipi tea, so she better look slightly perplexed. She's at a French style bistro called Farm to Table. The diner is a little perplexed because she has three menus in front of her already, and here comes the waiter with a fourth menu saying, Good evening, ma'am. Welcome to Farm to Table. As a Vermont resident, you may select from our Vermont drug discount card price list as well.

[Rep. Alyssa Black (Chair)]: Remind me what WAC is.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: That's wholesale acquisition That's cost or WAC, my initials. So why is that a good thing? Why is this a good thing for this diner to receive a fourth menu to choose from? And I do think it is a good thing. First off, she can get rid of that WAC menu, the WAC menu. This is a menu where all of the prices are manufacturer list prices, and you do not want to be paying manufacturer list prices. She also has that PBM menu in front of her. This is the menu of the drug selected by her health plan's PBM, in the PBM's preferred tiers and with the PBM's negotiated prices, which may or may not be the best prices or even good prices at all. Perhaps the diner's PBM for reasons unknown to her is requiring her to pay full price for her medications. It's not unheard of, and it's definitely unfortunate for her. And that last menu on the table, cost plus, what is this cost plus menu? I want to deviate from my presentation for just a second. I'm going to advance this slide here. And what I'm going to show you is a screen grab from a slide deck accompanying the Green Mountain Care Board's prescription drug affordability report, which you all now have in your hands. I wanna give a shout out briefly to the group GMCB pharmacy team for their excellent report, exciting recommendations. I'm hoping you're gonna be hearing from them soon. One of their recommendations is for Vermont to explore a voluntary opt in to cost plus pricing for generic medications in particular. And without going into the weeds on what cost plus pricing is, cost plus pricing refers to a pharmacy reimbursement model where pharmacies get reimbursed what they actually pay for a medication. That is to say their acquisition costs plus a professional fee on top of that acquisition cost that enables the pharmacy to make a small margin on the transaction. By GMC's analysis, this is covered in their report, adopting a cost plus model for generics could save Vermont $23,600,000 annually. I think I got that number right. What this slide in particular shows, and this is why there are multiple slides, I chose this one in particular. What this shows is the potential savings on an individualized drug level. So you see all the drugs listed over there on the left. The savings that could be achieved by adopting Cost Plus. And you can see the percent savings over here in this right hand column, and you can see that they're all in the range of 90 plus percent savings on each of these drugs. And you can see there's a scroll bar here, and you can scroll on to this. This is a long list of drugs. And they're not all in the 90% range, but there's a tremendous amount of savings here. And what this slide shows to me, each of these lines represents a Vermonter or many Vermonters who are overpaying for these medications. This data that GMC is using is vCure's data. This is actual claims data from Vermonters, and each of these lines represents someone who is overpaying for for drugs and a system that's overpaying for drugs. But as a as a consumer advocate, it's it's it's the individuals that I'm thinking about who are who are overpaying. So I want to get back to our diner. She has that Cost Plus menu on the table. Cost Plus is a recommendation from the GMCV. It's in their report. It's not operationalized here in Vermont yet. It's technically an option for her because there's something called the Mark Cuban Cost Plus Pharmacy. It's an online pharmacy. All of us could go and use it right now. But it's an out of state pharmacy. It's an online pharmacy. It only stocks limited drugs. If you read their Google reviews, they have a problem with customer service. So if you send your prescription to Cost Plus Drug Pharmacy and you have a problem with it, it sounds like it could be a nightmare. I might get an angry call from Mark Cuban after this for saying that, but he's probably not listening, I'm sure. Anyway, so that cost plus menu might not be a viable option for her. That whack menu, she's not gonna wanna use that. So now we have the waiter bringing her that fourth menu, that Vermont drug discount card price list, and that's the benefit of this program. It gives this diner, this Vermonter, another set of options. She should look at that menu carefully, and she might find some good deals in there. Certainly a better deal than that WAC menu, maybe some better deals than in her PBN menu. And unlike Cost Plus, the Vermont Rx prices are available to her right here, right now in Vermont at most of her local pharmacies. And as we've heard, ArrayRx won't share her data or try to sell her a premium discount card experience, which is something that GoodRx does. And it's all free and available for her to choose simply by being a Vermonter. So I promised you a real live example from a Vermonter. So I'm going to go ahead and share my own personal experience. So it's January, the most dreaded time of the year. My deductible and out of pocket maximum accumulators have been reset back to zero, and I'm facing I have a $4,000 deductible and a $4,000 out pocket maximum. I'm facing a $4,000 bucket I have to fill, and I have immediate expenses. I have a chronic condition. I treat it with medication that I fill every month, and it's expensive. The medication went generic two years ago. I was super excited. I thought now it's finally going to be cheap. Nope. Even generic drugs can be very expensive. So here we are. I've entered the drug into my health plan's drug pricing portal, and here's what they're telling me I have to pay. Dollars $18.36 for a one month prescription. Good grief, that's a lot of money, right? Especially since I know this medication does not cost anybody in the distribution chain from manufacturer to wholesaler to pharmacy. It's not costing anybody $18.36 dollars. Nowhere near it, in fact, as we'll see, but that is what my health plan is telling me it will cost me. What about Mark Cuban Cost Plus? I already said there's this online pharmacy that everyone can use. I went to Cost Plus. I see Cost Plus was gonna charge me $63.46 for this drug. And you can see they break it down further at the bottom, the manufacturing, their markup, their labor fee. The actual cost of this drug is $50.83. They tacked on $13 for their markup and their their their dispensing fee, it's $63.46. That's a savings for me off of the 1,836 of 96.5%. A crazy amount of money. Right? A crazy crazy amount of savings. What about ArrayRx? So I used their price lookup tool and entered in my medication, and I found here's the list I got. I do wanna point out here, this is just a very small list, but this is zeroed in by zip code. So there are all kinds of pharmacies that you can use as you've already heard. This was just for this example. And so the prices that ArrayRx is offering me or the Vermont drug discount card would offer me is $73.47 at one pharmacy and a $106.58 at some others. Really not bad. And although it doesn't give us the breakdown into acquisition cost plus margin, we know from cost plus pharmacy that we can see that the RA Rx price is in the range of cost plus pricing, and indeed the savings to me is roughly equivalent, 94% to 96%. So that's my example. The Vermont Drug Discount Card would unlock these really significant savings for me, and the one thing I know is that I am not unique. If this card could help me, it could help others, and indeed, thinking back to that GMCV slide I showed you earlier, all those people who are overpaying, all those Vermonters overpaying for their prescriptions, potentially, this card could help them too. But and, of course, there's always a but. We've been talking about this. I've been hearing chatter about this all morning. What if the spending doesn't count? On the surface, this decision I'm facing seems like a very easy decision to make. Pay $1,800 for my medication or pay 100 ish for my medication. If the spending counts, it really is an easy decision, but if it doesn't count, then that decision becomes much more complex. If you'll bear with me, I'll go through some of the details. If the spending doesn't count, you're faced with a choice. Use your insurance or use your discount card. If you use your insurance, and again, this is my example, then you end up vastly overpaying for your medication. This is option one up at the top. You can see $1,800 in January I will pay, another $1,800 in February, and maybe I'm putting this money on a credit card because it's January. Right? And the holidays just happened, and we have the holiday bills, and and it's the the heating time of the year. I've got heating bills, and it's tax season. I might have a tax bill coming up. January is a very expensive time of year to have a $1,000 $1,800 medication expense come up that you have to pay on a monthly basis. But then you get to March, and there's only $400 left in my out of pocket maximum, and so I pay that $400. I hit my $4,000 out of pocket max, and then I get free health care for the rest of the year. I heard representative McFaun alluded to this earlier. And I put free in quotes because, of course, it's not free care. It's free to me, but insurance would pay that bill, the system will pay that bill, Vermonters will end up paying that bill, but it would be free for me. And that's something I think that's called an insurance parlance. I think that's called moral hazard. It gives me sort of an incentive to maybe get care I don't need. But anyway, that's option one. Then there's also option two, using the discount card. This is again using that ArrayRx price of $100 ish a month times 12, knowing that I'm gonna fill that prescription 12 times a year, that's $1,200 in medical spending that will not count. Again, is if the spending doesn't count. I'd be paying a way more reasonable price for my medication, 100 a month versus $1,800 That feels better to me, right? And it also hits my budget in a much more manageable way, 100 a month versus $1,800 in a single month. But it also introduces this new anxiety point of $2,800. So what is this new anxiety point? With a $4,000 out of pocket max and $1,200 in uncounted spending, I'll have to be reasonably certain that my other medical claims for the year will not exceed $2,800. Otherwise, I'll have gone over $4,000 in medical expenses and I'll have made a bad economic decision. Potentially, in this example, a bad economic decision that could cost me $1,200. So that's why I had this big warning in the middle of the slide that these are fraught choices. And again, I know I heard some of this discussion already happening this morning. In my example, this is actually pretty simple. High deductible and out of pocket max are the same, which makes the calculation easier, and it's a flat dollar amount for the medication, and it's just one medication. This is not multiple medications. Other people's plans and situations are much more complicated. And each nuance you add to the calculation, it makes gaming out those scenarios of, is this going to benefit me, it makes it that much more complicated. And that's why it would be perfectly reasonable for many people to say, if it's that complicated, I'm just going to use my insurance. But that's the discount card spending if it doesn't count. If it does count, then it is truly an easy decision. You take that best price you can get, and why wouldn't we want everyone to get that best price that they can get? So what do we know about whether or the spending counts? This is from the RA Rx website. So we know what they say on their website. This is one of their frequently asked questions. Can I use the RA Rx discount card if I already have insurance or Medicare? And the answer is yes, you can use the card instead of insurance, and I've underlined that in the first line. And then the final sentence is also underlined here, ArrayRx discount card purchases will not count toward your deductible or out of pocket maximum. They're not even hedging there with a may not count. They're saying this will not count. So that doesn't inspire a lot of confidence, but this is just a public facing national website not tailored to any specific state. And ArrayRx is presumably not speaking to the nuances of state health law in this FAQ. So again, I think it's still an open question. Will this spending count? So what does Vermont law say? Here's another lot of text on this page. This is 18 BSA 3,612, as amended by Act 127. This was the PBM licensure bill you all passed a few years ago, where we had the co pay accumulator language added. So let's tackle this middle paragraph here first. This is 36.12e two a. A pharmacy benefit manager shall attribute any amount paid by or on behalf of a covered person under subdivision one of the subsection e, including any third party payment, financial assistance, discount, coupon, or any other reduction in out of pocket expenses made by or on behalf of the covered person. So all those payments, a PBM has to apply those towards your deductible and out of pocket maximum. That language seems pretty clear. Any amount paid by or on behalf of a covered person must count. So if I'm going to the pharmacy counter, I'm using the Rx card, that's an amount paid by me on my behalf, which should count. That's one theory, but there's a lot of language on this page. And it starts to get a bit circular when you follow the cross references here. And it's that cross reference in this paragraph that has me concerned in particular. It says, spending pursuant to subdivision one of this subsection E. So what does that language say? So that's this language up here. And I have to say, this is my favorite language in all of the Vermont statutes. It says, a pharmacy benefit manager shall not require a covered person to purchasing a covered prescription drug to pay an amount greater than the lesser of the cost sharing amount under the terms of their health benefit plan, as determined in accordance with subdivision two of the subsection E. So there's some of that circular logic I was referring to, it brings you back down to that second paragraph. But so, your cost sharing, the maximum allowable cost, I won't get into explaining what that is, it's not particularly relevant, or C, the amount the covered person would pay for the drug after application of any known discounts if the covered person were paying the cash price. And so it's this last one where I'm like, okay, so again, I'm at the pharmacy, I'm using the ARA RX card. Am I paying a discounted cash price that the PBM has to give me credit for? Again, I think this is the interpretation that some people I've spoken to, including people at DFR. It's great to hear they're going bring DFR in to talk about this. I had a conversation with people at Blue Cross of Vermont. There are people who think this language applies and means this spending must count, But I can't help but think, if I'm a PBM that doesn't want to give credit to the spending, for whatever reason they don't want to give credit to the spending, they're going to say, by using the discount card, that covered person has cut that PBM out of the transaction. And therefore, we are not the PBM to whom this language applies, and nor is the covered person someone to whom those protections apply, because for this transaction, we are not the PBM, the discount card PBM is. And for the purposes of this transaction, the covered person is not covered because they've opted not to use their insurance. Think that's what they're gonna say. I'm not saying that's what my reading of the law is necessarily, but I think that's what some PBMs would say. And I have to say, as a consumer advocate and as a lawyer, it makes me nervous. I would not feel like I was on solid ground giving someone the advice based just on conversations I've had with people and my own interpretation of the statute that, yeah, you can go ahead and use that discount card and that spending is going to count. So for me and for the HCA, I think this question about whether or not the spending counts under the law and will count in practice, it's a concern that makes us want to hedge our support a bit. We think the bill would be stronger if paired with clarification to the statutory language. And over the summer and it's interesting that there was we had Connecticut folks on the on the call earlier on the in the meeting earlier, and I think I heard multiple times that Connecticut was is saying that a discount card spending doesn't count. And that is surprising to me because over the summer, I saw a headline that caught my attention, and the headline was something like Connecticut governor signs GoodRx bill. I thought, what's the GoodRx bill? So I looked it up, and here we have Connecticut Public Act number twenty five one sixty seven. I've highlighted a portion of it here. It's complicated statutory language. I'm not going to read it out for you. What I am going read is the governor's signing statement. I mean, and I provided links here. People can follow, and this is the governor's signing statement to this bill. I support, in particular, the bill's assurance that when consumers use discount programs such as ArrayRx and GoodRx, those purchases will count toward their health plan deductibles and make it easier for families to get the medications they need at the lowest prices. End quote, that's the Connecticut governor. This is legislation that they enacted this year. Maybe it's not in effect yet. Maybe it just went into effect, and not everyone's aware of it. But or maybe we misunderstood what was said earlier today. I'm pretty sure in Connecticut, the position is the spending has to count. And that would be our HCA recommendation to this committee. If you all want this spending to count, then we think you should spell it out and make it as clear as you can in the bill language and in your discussions here in this committee that you want that spending to count. And there is some a little bit of nuance here. And I'm gonna try to articulate the nuance quickly. The spending needs to count when it's provided for when used to pay for a covered drug at a lower price. Right? Like, the spending's not gonna count if you just buy some drug that's not covered by your health plan. The drug has to be covered by your health plan, and you have to get a better deal. The PDN, you're not gonna get credit for overspending. It has to be for a covered drug for which you find a better deal using a discount card like our IRX. That's how I read this language, and that's what I would suggest you do as well. I have one more suggestion for you. I just could not let this pass. Last year, representative Cordis introduced h two zero two. So this is bill language from h two zero two. That bill is still up there on your wall, and there might be similar language coming your way in a different form, in a different bill this year. But I worked with representative of Cordis on h two zero two, and I can tell you that the purpose of the language down here at the bottom in subsection e one b, The purpose of that language was to clarify this exact thing, and what it says is, as used in subdivision a three, that's the cash price prong of that greater than the lesser of list of three, so cost sharing, maximum allowable cost, or cash price. This defines cash price to mean that it's the actual amount the individual would have paid if the individual purchased the drug without coverage for the drug under any health benefit plan, which shall include the lowest possible price the individual would be able to obtain by using a drug discount card. And that is language that was I worked with representative Cortez on this, and and and your alleged counsel worked on this language as well. So this isn't language that is made up. Right? I like this language too. I think it's pretty clear what it's trying to do. It might even be clearer than the Connecticut language. I don't know. You guys have more discussions coming. It sounds like ample more testimony is on the way for you on this topic. So for me, to wrap up, we support H577. Without any amendment, it would make available to Vermonters a set of discounted drug prices on a very broad selection of drugs and at a wide network of pharmacies. There is value in that, and some Vermonters will find deals. Those deals would be stronger, and this bill would be stronger by amending the bill to include language, whether that's the Connecticut language or the h two zero two language, clarifying that the discount card spending must count provided that it was for a covered drug at a better price. And lastly, you can see here on the screen, I just wanna plug an HCA resource. This is our prescription drugs page. The URL is at the bottom. There's also a link to our HCA web intake and the phone number for our phone intake line. Prescription drugs

[Rep. Alyssa Black (Chair)]: are

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: expensive. Coverage options are confusing. It's really, really easy to make a mistake or to feel like you don't have any options. This page lists other resources that are available to Vermonters, including those expanded MSPs, including V Pharm, including Healthy Vermonters, hospital financial assistance. There are a lot of programs out there. You can research them from this page, or you or your constituents can call or fill out the web intake. And that's what I have for you. Are there any questions? Karen,

[Rep. Alyssa Black (Chair)]: thank you. Thank you. Thank you, that was great.

[Unidentified Committee Member]: I'm a Chittendenary Cortez.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Oh, I see you in her seat, yes.

[Unidentified Committee Member]: I'm in her district,

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: all those Oh, perfect, yeah.

[Unidentified Committee Member]: She's gonna be visiting tomorrow, so

[Rep. Alyssa Black (Chair)]: I'll be able

[Rep. Leslie Goldman (Member)]: to tell her that.

[Unidentified Committee Member]: So if you're at the pharmacy and we take the advice or the amended language, does the pharmacist, do they know this is a covered drug at a lower price and they can say to the person, yes, it is one

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: of those.

[Unidentified Committee Member]: That's a great question. Be sure.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Yeah. Well, it would be ideal if that were the case. Mhmm. Honestly, I don't know how this would work. I think some of this is still gonna be on consumers to do a little bit of that research for themselves. Right? And and I think it might, unfortunately, be even a little bit more complicated than just doing your own research, making sure the drug is covered first, and making sure you're getting a better price. I think there's still gonna need to be some sort of manual claims reconciliation. Like, if you decide the Aurea Rex price is the better price, I want to use that price and I want it to count, your health plan PBM isn't gonna have any way of knowing that you've maybe done that Spanish because they're not involved in that transaction. You've used an ARX for that transaction. So you're going to have to, I think, file a manual claim with your health plan to sit and provide proof that you purchased a covered drug at the price you purchased it and request credit for that purchase from your health plan. That's how I think it will have to work. I don't think it's going to be seamless.

[Rep. Alyssa Black (Chair)]: Yeah, I was thinking that too, I'm like, how do they even know?

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Yeah, yeah.

[Rep. Alyssa Black (Chair)]: So it is going be a process. Keep going.

[Unidentified Committee Member]: And just one follow-up. So in a health insurance account, is that the same? Would it work the same way? I mean, that

[Rep. Alyssa Black (Chair)]: the equivalent of a PPN?

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: A health savings account or?

[Rep. Alyssa Black (Chair)]: Yeah, health savings account, like you had to

[Unidentified Committee Member]: get the bronze plan because everything else is too expensive, and so you're self funding your own insurance, you put money in here for this drug purchase. Is that, again, language would cover that

[Rep. Alyssa Black (Chair)]: and say you can use?

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: I think you can use your HSA. I think you can. Mean, I don't know why you wouldn't be able to, but I might be going too far over my skis on that one.

[Rep. Alyssa Black (Chair)]: So it might be a

[Unidentified Committee Member]: deductible on that too, I don't know, I was just curious how that would work too.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: You. Good to meet you, please tell our audience that I will.

[Rep. Alyssa Black (Chair)]: Any other questions? I had a question to which I lost my mind because I have like 10,000 things going through my mind about this. You did mention you you're at the point of sale. Don't we have something where the pharmacist I'm channeling Mari. Don't we have something in statute where a pharmacist has to tell you if the self pay price is less than the insurance?

[Colin Hilliard, Advocacy Director, AARP Vermont]: Well, can tell

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: you that, but that was a part of

[Rep. Alyssa Black (Chair)]: it

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: They

[Rep. Alyssa Black (Chair)]: offer you the lower yeah. They have to, like, offer you they have to inform you that you could be paying the lower price.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: I'm not entirely sure, chair of black, to be honest, but I do know that that was wanna revisit H 202. That was in H 202 that I think what what we landed on in H 202 was pharmacies needing to put a notice at the counter saying, you may inquire about other prices that may be available to you, is I think what we landed on in that bill. I'm not aware of any affirmative obligation by a pharmacy to tell you about other pricing options.

[Rep. Alyssa Black (Chair)]: You were sitting there talking about cost plus, and I have not had a chance to read the Green Mountain Care Board's prescription, although I hear it's a fantastic report. So I'm really looking forward to it this weekend. But to Topper's point, which it's all funny when he says it, but it's sort of true, why don't we just get rid of If cost plus could save Vermonters 96.5%, why don't just blanket get rid of why don't we just make it so that if you purchase a drug in the state of Vermont, you will pay the pharmacy's acquisition cost plus 2% for them to be able to administer it because obviously they've got to make a little because they're doing a job. Why don't we just do that?

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Chair Black, you were speaking my language.

[Rep. Alyssa Black (Chair)]: Name. PBS.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Oh, mean, I don't know if that would effectively ban PBMs. I mean, there are PBMs that work on a cost plus model. I mean, I think what you would be you'd still need someone who administer your pharmacy benefit, and that might be a pharmacy benefit manager, but you would be directing your PBM to implement cost plus pricing. I mean, there are PBMs that do it. And I think the what the Green Mountain Care Board report is suggesting and they should speak for themselves, I don't wanna do it just a disservice. They're recommending a voluntary opt in to cost plus. I agree with you, Maybe we should just go all the way and and say that pharmacy reimbursement in the state of Vermont will be based on actual acquisition costs plus a reasonable professional fee for pharmacies. It's a discussion that's definitely worth having. So And I appreciate you bringing up that point.

[Rep. Alyssa Black (Chair)]: Because we could do essentially all the qualified health business.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: I think we could. It's exciting. Keep those thoughts going.

[Rep. Alyssa Black (Chair)]: Okay, thank you so much.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Thank you so much.

[Rep. Alyssa Black (Chair)]: Really appreciate it.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Thank you

[Unidentified Committee Member]: for being And

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: if we

[Rep. Alyssa Black (Chair)]: have more time, we might have you back in.

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: Absolutely, anytime. Wanna take your quarter.

[Rep. Alyssa Black (Chair)]: Oh, hi. Okay. Okay. Nice to have you,

[Colin Hilliard, Advocacy Director, AARP Vermont]: Thank you for having me. I know we're up against lunch, so I will be keeping my Yeah. It's

[Rep. Alyssa Black (Chair)]: it's more that several of us have, like, places to be exactly at noon. Gotcha.

[Colin Hilliard, Advocacy Director, AARP Vermont]: Well, thank you again, chair, for having me and members of the committee. My name is Colin Hilliard. I'm the advocacy director for AARP Vermont. AARP is the nation's largest nonprofit, nonpartisan organization dedicated to empowering Americans 50 and older to choose how they live in age. On behalf of the nearly 38,000,000 members nationwide and 110,000 members here in Vermont, we appreciate the opportunity to speak in support of age five seventy seven. Prescription drug prices in The US are among the highest in the world, as we know, and for older adults and others on fixed incomes, increasing prescription drug prices can lead to difficult decisions and fatal outcomes. According to a recent AARP survey, eighty two percent of adults 50 and older report taking prescription drugs regularly, and yet a 2024 report from the CDC highlights that accessing these drugs isn't necessarily always simple. One in five older adults do not have insurance coverage for prescription drugs, And even for those with prescription drug plans, paying for medications can be expensive. As a result, some older Americans are skipping doses and delaying refills. And just this last year here in Vermont, we had our 2025 Vital Voices survey, where we survey Vermonters 45, and we found that eighty four percent of adults mentioned being able to afford prescription drugs was an important financial and retirement issue. That was the same amount that mentioned being able to travel independently. This is something really top of mind for our members here in Vermont. And so we see this H577 as a way to take some direct action on that, something that is within the state's control. This is not a silver bullet to solve all of our prescription drug prices, as I know you all have heard, but this is something that we're very supportive of, AARP has long supported bulk purchasing programs, which is a smart, proven way to lower prescription drug costs. By joining forces with other states, we can amplify our negotiating power, reduce administrative waste, and create real savings. Furthermore, I think this is a really critical time with the loss of the ACA premium tax credits. This is something that's impacting thousands of Vermont aged 50 64 here in Vermont. Many of these folks just in the last few weeks have become uninsured and under insured. And so we think that accessing a free drug discount card program like this is something that could be really helpful for them. And lastly, I just wanted to talk about the implementation of this program and how can be a partner and support that. I know the treasurer mentioned that we worked with them in

[Charles (Charlie) Becker, Staff Attorney, Office of the Healthcare Advocate]: the past

[Colin Hilliard, Advocacy Director, AARP Vermont]: on implementing the Work and Save program, Vermont Saves. I think that's something we're really well positioned for, being able to reach out to our 110,000 members in Vermont. We have a lot of experience in communicating with them and how to educate them on new programs like this. And so we'd look to be a really strong partner in getting the word out. I know there's a lot of discussion here and things still to figure out about whether the spending can count towards those deductibles. We're absolutely in favor of that and hope the committee will dive into that further. That would certainly make our education efforts much easier in getting the word out and having older Vermonters understand that. And that's my testimony. Happy to take any questions.

[Rep. Alyssa Black (Chair)]: I just I wanna I really appreciate you mentioning because this is testimony that we heard that with the loss of the enhanced premium tax credits, Diva did come in and tell us that they don't have the numbers yet on people who have totally dropped, but the overwhelming thing that they have seen is that people have gone from higher metal levels with less out of pocket costs to lower ones. And I'm looking at the plan designs and a family stacked deductible is $20,000 So filling that $4,000 bucket of like Charlie has, imagine trying to fill a $20,000 bucket. So I really appreciate you mentioning that because we know that this is something that Vermonters are really, really struggling with right now. Leslie? So one of the things

[Rep. Leslie Goldman (Member)]: I think they're struggling with in Connecticut is getting the word out and getting people to sign up. So I'm very excited to hear that you're willing to be one of the people out in the world promoting this program. Absolutely. That's very cool. So how do you see that?

[Colin Hilliard, Advocacy Director, AARP Vermont]: Thank you. I've been in contact with our Connecticut office already. They were supportive of the bill down there that enabled this. And so we're looking to learn from them on in a discussion with them about what has worked and what hasn't. And this is something that I think a number of our state offices across the country are looking to engage their legislatures on past bills like this. So there's an increasing amount, I think, of resources within AARP to do this. I don't have all the answers on that yet, but we're definitely working with people at our national office and in Connecticut about how it is best to roll this out, get the word out, using things like direct mail, telephone town halls. We have the Bulletin, our monthly newsletter that goes out to folks. So we have a number of ways to reach our members and help educate them. That's work that we've been doing for really a long time. How do you enroll in Medicare, and understanding how your social security, when it takes social security. We've been doing that work for a long time, and we see this right in line with that.

[Rep. Leslie Goldman (Member)]: Thank you for that.

[Rep. Alyssa Black (Chair)]: Any other questions? Alright, thank you for coming. I really appreciate it.

[Colin Hilliard, Advocacy Director, AARP Vermont]: Absolutely, thanks for having me.

[Rep. Alyssa Black (Chair)]: We'll be back at 01:00. No, what room are we in? Eleven. So we're in Room 11 at 01:00. We have a joint committee hearing with Human Services. And just to let everyone know, we are coming back here after the floor today. Okay? So I'm not going to stand up on the floor and tell you ten minutes after floor, please be