Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: I'll say card because that's my Buffalo accent, but that's your Boston Cot Welcome back, everyone. So Jen is going walk us through some language around five seventy seven. Just to let you know, we're going to have some testimony on this tomorrow, so we don't have to have great committee discussion around this. But I just wanted to introduce the language so that we could all take a look at it. Great.

[Jennifer Carbee (Office of Legislative Counsel)]: Good afternoon. Jen Carvey from the Office of Legislative Counsel. I will put language up on the screen. It's currently a strike all amendment to h five seventy seven.

[Jennifer Carbee (Office of Legislative Counsel)]: There's some changes in a few different places. H577, as a reminder, is an act relating to establishing the Vermont Prescription Drug Discount Card program. And we've had some discussion earlier this week and maybe late last week about how you wanted to handle some existing provisions of law that require a pharmacy benefit manager to to require the patient pay more out of pocket than the lowest cost, their lowest price that would be available after application of all discounts if they were paying for the whole thing out of pocket. And so this still sets up the Vermont prescription drug discount cards program. I added in a nod to those other sections, and then we'll go in and actually amend to those sections, but added in a new subsection D saying the amount paid for a prescription drug after application of the Vermont Prescription Drug Discount Card by an individual who is covered by a health insurance plan as defined in the health insurance chapter shall be attributed toward the covered individual's deductible and out of pocket responsibilities in accordance with eight BSA Section 4,093 and section thirty six twelve of this title, which is Title 18. And that's just making it clear how it works together. Oh, and then there was one other addition too, after some of your committee discussion as part of the annual reporting on the program, the treasurer's report would include not just the activities of the program and how many people participated, but also the balance in the Vermont Prescription Drug Discount Card Program Fund. So I think that was an issue raised by Representative Demar. So that is in here now. Great. Okay. Sure. All right. So then we have a new Section two that would amend that eight BSA Section 40 nine-three. Under the existing laws, this is in the health insurance statutes. We deal with this idea of attributing amounts somebody pays out of pocket to their deductible and out of pocket maximums in two different places in the statute. We deal with it in the health insurance chapter and it applies to health insurers and pharmacy benefit managers in that chapter. And we deal with it again in the pharmacy benefit manager chapter where we basically say the same thing, but a little bit of a different format. So you'll see there's a little bit of different terminology between the two chapters. We're not trying to fix today because that's a bigger issue. But we're at least trying to make the language consistent. So under existing law, a health insurance, a health insurer or a Pharmaceutical Benefit Manager, a PBM, must permit a participating network pharmacy to perform all services within the lawful scope of the profession of pharmacy. And a health insurer or PBM shall not do any of the following. And there's a list, and this is so we're jumping ahead to Subdivision F on that list. And so the health insurer or PBM shall not exclude any amount paid by or on behalf of a covered individual, including any third party payment, financial assistance, discount. I added discount card in here. I don't know that that's strictly necessary, but in case there's any question, there's a difference between a discount and a discount card. Coupon or other reduction, and then adding in regardless of whether the individual purchased the drug with or without using coverage for the drug under any health insurance plan. So whether they use their insurance or not. So health insurer PBM shall not exclude any amount that the person pays or has paid on their behalf for the drug, regardless of whether it was being purchased using the insurance or not using the insurance. When calculating their contribution toward their out of pocket limits, so we have out of pocket limits in statute for prescription drug spending, after which the person doesn't have to spend more out of their own pocket, The covered individual's deductible, if they have a deductible, or to the extent not inconsistent with federal law, their annual out of pocket maximums. And then there are certain parameters, certain limitations on that application to those out of pocket limits and deductible. It says it only applies to a prescription drug, and this again is existing law, for which there is no generic drug or interchangeable biological product, which is basically the biologics version of a generic, or for which there is a generic drug or interchangeable biological product, but for which the covered individual has obtained access through prior authorization, a step therapy protocol, or the PBMs or insurers exceptions and appeals process. So that's some limitations on an existing law on when that application to their out of pocket must apply. And then another limitation saying the provisions of that requirement apply to a high deductible health plan only to the extent it would not disqualify the plan from eligibility for a health savings account under federal law. I think we talked about this in the past as well. So not changing that existing law, but now adding in a new piece based on some language in Connecticut's law. And this would say, In order to facilitate the appropriate attribution of amounts paid by or on behalf of a covered individual pursuant to subdivision one, that's the part that says you have to apply it to their out of pocket maximums and deductible, in order to facilitate the appropriate attribution of those monies for a covered individual who purchased a prescription drug without using the prescription drug coverage available for the drug under the covered individual's health insurance plan, the insurer or PBM or both must First, make readily available on its website a downloadable proof of payment form for a covered individual to use to submit proof of the actual amount that the covered individual paid for the drug and two, provide notice to all covered individuals at least annually that they are responsible for providing proof of payment using the downloadable proof of payment form or another mechanism if the insurer or PBM elects to make another mechanism available for submitting proof of payment in addition to the downloadable form in order to have their spending properly attributed to their out of pocket limits, deductible and out of pocket maximums as set forth in subdivision, permanent ones. And then it basically does the same thing in Section three. So Section three is the existing statute on Preventive Practices for Pharmacy Benefit Managers. We're moving everything kind of down a level so that I can add some additional stuff into this subdivision E1. So these pieces don't change, but this is where the existing language, we looked at this earlier in the week, says that a PBM shall not require a covered person purchasing a to prescription pay an amount greater than the lesser of the cost sharing amount under their health plan, the maximum allowable cost for the drug, or 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 then this adds in some language. This is some of the language that the Health Care Advocates Office had proposed that was in a bill last year, H202, that you took a piece out of, but not this part. And this clarifies that as used in Division A3 of this subdivision E1, cash price means the actual amount the individual would have paid if the individual had paid 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. Then we have language like we looked at in the previous section requiring the PBM to attribute any amount paid by or on behalf of the covered person in any way and adding in that specific reference to the discount card in case there's confusion about whether that's included in discount. And then adding in regardless of whether the individual purchased the drug with or without using coverage for the drug under any health plan toward those out of pocket limits, deductible and maximum annual out of pocket maximum, the extent allowed under federal law. We have, again, the limitations that it doesn't apply if there's a generic or interchangeable biologic unless the person has gotten authorization in another way. The provisions, again, this is existing law, only apply to a high deductible plan as long as it wouldn't disqualify the plan from eligibility for a health savings account. And then adding in the same language with just a couple of tweaks of terminology because of the way the language reads in this section in order to facilitate the appropriate attribution of amounts. I don't need to read the whole thing to you again, but they used to be covered person rather than covered individual here. The rest of it is same and that takes out references to health insurers, just PBM. Realizing here I think it may say health benefit plan, not health insurance plan just because of it quirking the way the terminology is in this chapter. And then I just renumbered the remaining sections.

[Alyssa Black (Chair)]: Would it be possible for you to just really in plain language explain what we've just done with this. Have we done? So

[Jennifer Carbee (Office of Legislative Counsel)]: with all of this language, the language both makes clear or kind of doubles down on the requirement that the insurer or PBM attribute anything the person spends out of pocket when they use the RARX card or another drug discount card to the person's out of pocket responsibilities under the plan and directs the insurer to make, or NPBM, to make available a way for somebody to provide proof of payment and clarifies that it is the responsibility of the individual who got the drug to file that out of pocket payment, proof of payment with the insurer PBM.

[Alyssa Black (Chair)]: Great. Doctor.

[Leslie Goldman (Member)]: Quick question. On line 14 on page nine. Page nine. It talks about providing notice to all covered firsts, At least annually that they're commercial for providing the proof of payment using a downloadable form or another mechanism. And then it goes on to say, if the pharmacy benefit manager elects to make another mechanism available for submitting proof. So if they don't, I'm picturing an elderly person who doesn't know how to run a computer or anything else.

[Alyssa Black (Chair)]: How do they do that? If they're,

[Jennifer Carbee (Office of Legislative Counsel)]: I know your definition of elderly, they're probably on Medicare and this wouldn't have led.

[Alyssa Black (Chair)]: Okay. That's right. I

[Jennifer Carbee (Office of Legislative Counsel)]: believe the Connecticut language just said downloadable form. And I thought on the flip side that an insurer might wanna make an online, a way that somebody could do it fully electronically without downloading the form, which is why I put in the language suggesting they might elect to make another mechanism available as well, but having the downloadable form be the default, if they could do a second way.

[Leslie Goldman (Member)]: I think it's good advice for you.

[Alyssa Black (Chair)]: And just to I remember when Blue Cross was here testifying that they actually If already have you go on their website, they have a PDF of the form you can print off and then they have a entry, a separate way that you can do it, which is online. It's like an online form submission. Fillable PDF that you can. And then you just send it. Great. So yes, that's that's what I can do. For thinking. Yes. Okay. Any questions for Jen? And then we're going to pivot to 06:11. Again, we're gonna have testimony on this tomorrow. Okay? Wanted everyone to see the language first. You're giving me a No, bright

[Leslie Goldman (Member)]: I'm just looking at you. I was looking at you wondering what you were gonna say.

[Alyssa Black (Chair)]: Did I say what you thought I

[Leslie Goldman (Member)]: was gonna say? Oh. Oh. You were gonna rush us to vote on it, so I'm glad we went

[Alyssa Black (Chair)]: on it. Oh, no. No. We're not voting on this. We're not even voting for tomorrow.

[Leslie Goldman (Member)]: It's the vote.

[Alyssa Black (Chair)]: I don't believe.

[Leslie Goldman (Member)]: No. Are you trying to

[Alyssa Black (Chair)]: sell? Next week. Okay. Second.

[Leslie Goldman (Member)]: I feel like we will never vote on this. Endlessly to it. 1.1. No.

[Jennifer Carbee (Office of Legislative Counsel)]: That's the one that we're working on this morning.

[Leslie Goldman (Member)]: Oh. Oh, yeah. We're gonna vote on it. We're just gonna amend it fiercely. Okay.

[Alyssa Black (Chair)]: If we just muted the room for a brief moment, well, don't want to end the live feed because we have witnesses who are there and then they would have to log back in. If if we talk You can go offline.

[Leslie Goldman (Member)]: You

[Jennifer Carbee (Office of Legislative Counsel)]: end the Zoom.