My wife and I will be celebrating five years in March since we opened our pharmacy’s doors. We have been an integral part of the Williamsburg community from day one; making a significant impact on those that reside here. Despite all of this, the tough position that the insurance companies and PBMs put us in makes it very difficult to serve our patients. There’s no way for us to stay in business with the unfair contracts that we are forced to sign as independent pharmacy owners; pay to play as they call it. We are in one of the only industries where we can actually lose money on a good that we sell. It’s not even like we’re asking to make hundreds of dollars on a product. In most cases we’re trying to simply break even instead of losing anywhere from $20 to $100 on a prescription. Put yourself in our shoes…whatever your respective careers are outside of being legislators…imagine being forced to pay someone for a service you’re providing….lawyers having to pay their client to keep them out of jail…surgeons having to pay their patients to perform open heart surgery…mechanics having to pay their customers to change out their transmission…this doesn’t make sense right!? This is pretty much the situation pharmacists are put in on a day to day basis and it has to END! We beg that you allow for us to simply refuse to fill prescriptions that we’re taking losses on and to take it a step further….we beg that you fix the reimbursement model completely!

Partners in Virginia Oncology Associates are in support of HB 1006 to prohibit mandatory white bagging & brown bagging requirements from payers. Cancer treatment by medical oncologists is now largely outpatient and is carefully coordinated with radiation and surgery. Many patients with Cancer are treated with concomitant radiation and chemotherapy. This requires that both occur on the day. Curative anticancer therapies for breast and colon patients must be given within a tight window after surgery in order to achieve the curative intent. Oncologists need to be able to assure that the preparation and administration are so that critical time windows can be met and the therapeutic benefit can be achieved. From a safety standpoint a majority of patients who receive chemotherapy need to receive white blood cell growth factor the day after chemotherapy. If the dose is not given in time, the patient is at significant risk of serious, potentially life threatening infection. Clinical changes may necessitate changes on the day of treatment and the physician needs to be able to accommodate the change with a change in therapy. In such situations, waste brown/white bagging would force the patient to wait for another time when the new regimen can be obtained and the originally intended drugs would be wasted. For these patient care reasons we support the prevention of white bagging and brown bagging by insurers who want to drive business to payer owned facilities. Thank you for the opportunity to address our concerns.

For years, we have been forced to accept payment for prescriptions that is below what it costs us to purchase. Some of these under-reimbursements have been hundreds of dollars below acquisition cost. While Rx plans do provide a means to appeal under-reimbursements on generics, I would say less than 1% of our appeals were granted in our favor. Brand name medications have been under-reimbursed more often and its become progressively worse. As a pharmacy, we have decided to no longer carry a very effective and popular class of weight loss drugs (GLP1s) for diabetics due to almost universal under-reimbursement. We filled approx 171 of these medications from 1/1/23-3/31/23 with many at a loss of $20 and some as high as $50. We cannot afford to stay in business if we are forced to accept losses such as those. At the very least, we ought to be able to decline to fill these rx's without facing fear of repercussions or losing contracts. We absolutely hate this situation for our patients, many who have been patrons of our pharmacy for decades. We are an integral part of our community and are willing to do whatever is necessary to take care of our patients but we have to be in business to be able to do so. I implore you to consider this bill giving pharmacists and pharmacies the ability to protect their businesses.

Thank you for your time. HB104 _ This bill allows a pharmacy to not fill a prescription if the PBM does not reimburse the pharmacy for the product. No one wants to turn away a patient, but if we are to stay open to provide service we have to be profitable. many times we pay $1000 and get reimbursed $950 the contracts we have to sign (no negotiation allowed) do not allow us to explain to the patient that can't afford to fill the Rx. If we continue patients will lose access to all medications because we will be forced to close. With rising costs and decreased reimbursements pharmacies in my area are already closing and more will come. This bill doesn't say we have to not fill a prescription it allows us to use our discretion. Odds are I will still choose to take care of these patients but won't be in jeopardy of repercussions from the PBM HB1006 Freedom of Choice. We are asking for the market to allow patients to decide where to get their prescriptions or medical devices. What could be easier to support. This would allow patients to choose with out any monetary penalty or reduction in reimbursement for choice. Patients know which providers and business have their best interest at heart at should be allowed to make that choice. Thank you for your time.

HB104 - This bill is more about ensuring access to medications by enabling pharmacies/pharmacists to make the tough decision to refuse to fill a prescription they know they will take a loss on. By pushing back against below-cost reimbursement rates from the PBMs, pharmacies will ensure their patients still have a pharmacy to visit. Too many pharmacies are closing down, creating pharmacy deserts in our state, due to 'take it or leave it' contracts from the PBMs. This will put them on notice to start playing fair or they'll need to answer to their customers.

Forcing pharmacies to bear the cost of uncovered prescriptions is unfair and a recipe for business failure. The repercussions of this (a lack of service) need to be anticipated and avoided. Please do not pass this bill.

I offer pharmacy services in 2 small towns, one in which I have the only pharmacy in the county (14 miles from the next pharmacy). If I contractually have to dispense prescriptions below my cost to purchase the drug product, sometimes more than $100.00 less, I can't continue in business. This will leave many without reasonable access to care, including Free Clinic patients, Medicaid patients and many without transportation options. Please support HB104.

We have seen issues pertaining to under-reimbursement on brand name medications for several years now as well as some generics. The volume of these under-reimbursements has significantly increased over the last year and has become an even bigger issue after Jan 1st of 2024. We're being forced to choose whether we can continue to carry certain critical brand name medications because we're no longer able to afford to dispense them. This creates access issues for our patients and reflects negatively on our pharmacy to those patients who've relied on us for years. What other business model is able to survive by paying consumers/patients to utilize their business services/products because that is essentially what is happening? That is not a sustainable model nor should it be permitted. Since PBMs are going to continue to under-reimburse pharmacies, a pharmacy should be able to decline to fill a prescription if it is going to negatively impact said pharmacy. This is very unfortunate for patient care which is ultimately the #1 priority, however, there will be no pharmacies to care for patients if pharmacies are forced to continue dispensing medications that are paid below their costs for fear of having the entire contract rescinded. We have an accredited Diabetic Self Management Education (DSME) program and a Diabetes Prevention Program (DPP) with CDC full plus recognition and we don't carry a single GLP1 medication because we cannot afford to dispense them at the losses we were experiencing. This is a very sad state of affairs for community pharmacy and its something that is in urgent need of being addressed. HB104 would be a very important step towards helping pharmacies protect themselves financially so they can keep their doors open and the lights on.

My father started an independent pharmacy in 1975, so I have grown up in the business and now have ownership in 3 independent pharmacies myself. In the last 20 years, PBMs have hijacked the industry, driving up drug prices while at the same time reducing patient care and positive outcomes. The number of prescriptions we are asked to fill that the PBM doesn't even cover the cost of the drug, much less the actual cost to dispense the drug, has grown exponentially. There is no other industry that routinely expects its providers to lose money and stay viable. The fact that the PBMs try to force us to fill at a loss, and threaten to revoke our contract if we tell a patient we can't fill the prescription because we are losing money, reeks of monopolistic and abusive business practices. Basically, the PBMs are telling us "we will pay you what we want to pay you, and you can do nothing about it". This bill will at least offer us protection and allow us to do what every other business in America is allowed to do--refuse to continually provide services at a loss.

As an independent pharmacist in Virginia for the past 17 years, I have seen the practice of below cost payment skyrocket. Every year it gets worse and worse, and the fear of losing your contract looms very large over our decisions whether or not we fill a prescription. In no other business, especially health care business, would you be expected to routinely provide something for less than what it costs. For many other health care providers they can send you a bill for the amount that your insurance company does not cover, we are not allowed to do that even if the patients would be willing to do it. We are just seeking protection from a practice that many do not even know happens. Thank you.

If pharmacies ARE forced to dispense drugs which are reimbursed at below that pharmacy’s cost there will soon be a time when no pharmacies will be in business to dispense any drug.

I encourage your support of this legislation. We are currently in an environment where we are expected to continue to take losses on prescriptions for serving patients. This cannot continue. We already are experiencing an industry shortage of staff and pharmacies are continuing to close and reduce hours. We cannot continue to try and help our patients when we are not able to even cover our costs of the medication dispensed. This will not address not being able to get an adequate dispensing fee to offset business costs. There is no other industry that is ham strung by PBM's (a contractor) of the insurance that requires you to take a loss and not be able to refuse the transaction or even explain to the patient why! We have had to stop carrying certain products and have been transferring prescriptions out that are too costly to fill. Ultimately, the patient loses because if we continue to fill these, we cannot stay open to serve our patients. There are already 5 counties in Virginia with NO community pharmacy. That number will increase if we do nothing to stop this abuse.

I have spent most of my 32 years as a pharmacist working for independent pharmacies. We know people by name, we know their families and we have relationships that create real healthcare. Unfortunately, I spend a lot of time trying to find ways to make sure we are not losing money when filling prescriptions and being heartbroken when I cannot stock something and have to send my patients elsewhere. I have been PIC at the only locally owned pharmacy in Greene County and as I have expanded the scope of practice (providing thousands of life saving vaccines during the pandemic, for instance) and increasing the amount of prescriptions we fill, I find that the revenue is not increasing and is actually decreasing. This is frustrating and scary and if we are not there to care, people will have to travel further and receive care from a revolving door of staff at the chain pharmacies. This is impacting our ability to pay our pharmacy technicians wages that they deserve and provide them with benefits such as affordable health care plans. All the while, insurance companies are dictating what we can dispense, how much we get paid, and what we can say to our patients while making record profits. Pharmacists play a vital role in triaging medical problems, being accessible, and truly caring for patients, but this is in jeopardy as profit margins are unsustainably low, and chain pharmacies try to centralize and reduce staff, reducing access to medical help. We catch drug interactions, prescription errors and build trust with our patients. This January has been especially difficult as I can see how the reimbursements are affecting the way I have to provide care. Please act quickly to stop this robbery of our locally owned pharmacies before they are all gone.

HB385: there’s an importance and safety to having two man crews.. safety for the company and the public.

Re: HB104. Through predatory pricing and criminally low reimbursement rates, large insurance providers are effectively destroying the practice of community pharmacy throughout the country, especially in rural areas. There are fewer independent rural pharmacies today than there were in 2023, and there were fewer then versus 2022. This trend will continue until insurance plans are held accountable at a bare minimum for fair reimbursement. No other industry operates in this manner, wherein a business is financially punished for working to provide lifesaving products and services for their community.

I am a pharmacist working in Amelia County. It is heartbreaking to see a claim submitted and we LOSE money. There is no other business out there that is asked to do work and lose money but pharmacies. We provide an invaluable service especially in rural communities (the Walgreens across the street is open less hours than we are and do not take certain insurance contracts that we do ex: Anthem Medicaid). If the PBMs continue to make us fill prescriptions at a loss -we won’t be here at all. In the end - everyone loses. There will be no Amelia pharmacy. Patients will be required to drive out of the county , while sometimes sick and asked to wait hours at a chain pharmacy. Most of our patients are struggling - barely able to afford things necessary for daily living - much less extra gas to travel or time to take off work. Many of them have no transportation at all. Insurance will suffer as well. ER visits and hospitalizations will rise. We all lose. We should not be forced to fill at a loss. If PBMs can’t pay us the cost to dispense, we should at least be able to tell our patients why.

Pharmacies are by contract being forced to provide medication to patients at below cost more now than any other time in my 40 years of being a pharmacist. The contracts we must sign are non-negotiable (take it or leave it). Because many of them are attached to larger PBMs, we can't refuse or "pick favorites" Many times to refuse a contract would mean the loss of 30% or more of our business. Additionally, reimbursements are so poor that we are unable to make it up on other things or prescriptions (the lost leader concept does not work here). This same reimbursement issue is behind the walk outs and poor working conditions in corporate pharmacies as well. This bill would allow us to not be forced to dispense at a loss (sometimes hundreds of dollars) and transfer that prescription to another willing provider able to serve the patient. We could then survive to service the rest of the community. This is now occurring daily and if we can't stop the financial harm, then pharmacy access is in danger!

We are losing more and more pharmacies and patient access due to the take it or leave it contracts and the PBM that insurance companies use that have no transparency on how they obtain their MAC pricing lists. I see on a daily basis prescription claims that are requiring me to fill a prescription below my actual cost. I am forced to take the loss or not stock the product and be unable to provide care to the patient.

I am a pharmacist working in Lexington, Virginia with my own business. I have many time Phil prescriptions at a loss with the inability to tell my customers that I’m being paid of course by their insurance that is not right Pharmacist should be paid at least the cost plus a dispensing fee to provide a service for the patient.

I have worked in an independent pharmacy since the age of 16 and have been a pharmacy owner since 2009. Pharmacies used to be reimbursed for the cost of medication and a fair dispensing fee, which covered the expense of labor and materials, and allowed us to provide valuable services to our communities. Over the years we have seen that plans no longer value the expertise and care that we give patients as drug costs are not being covered and in most cases, no dispensing fee is given. As business owners, we should have the freedom to let our patients know the real reason we aren't able to stock some of their medications. That the pharmacy is not being paid the cost to dispense, and in most cases, not even the cost to purchase. I would like to add that if the reimbursement issue is not addressed and fixed, there will be lots of communities without access to medication. Cumberland County, for example, has no provider and only one community pharmacy and we are hanging on by a thread.

I’ve been a pharmacist since 2003, started as a technician in an independent pharmacy, worked hospital, retail, and now back in independent pharmacy. I have witnessed firsthand the decreased reimbursements for prescriptions and our services and how this is affecting patients care and health. As independent pharmacists we provide services to our community when other healthcare is sometimes not available, if we are forced to fill prescriptions below our costs, our doors will close and so will the communities access to our services such as immunizations and diabetes care. In an environment where even retail pharmacies are decreasing hours due to inadequate staffing and their own reimbursement issues, patients are having to wait days for critical life saving medications. Patients are relying on their community pharmacies to get them their medications in a timely manner, for delivery services, immunizations, and many other services that they cannot readily receive elsewhere. If we are not even reimbursed for the cost of the product, or forced to fill prescriptions at a loss many in the community will suffer. We are having to downsize our staff, limit some of our services, and are considering shortening our own hours just to keep the doors open. I encourage you to support HB104. Without this change, the bottom line will continue to decrease, no new programs or services will be provided to patients, prescriptions won’t be able to be filled, and the doors will close. In the end, the one that suffers the most is the patient.

The Va Academy of Nutrition and Dietetics (VAND) strongly encourages reconvening this committee that has provided powerful Insights in the past to the disparities in Maternal Health and Mortality and highlighted Va’s higher levels in some population. Please support this important work for the Commonwealth as we work to improve access to care and improved outcomes for women and children in the state. Please reach out if we can provide more information on the role of nutrition in preventing poor outcomes in pregnancy And after the pregnancy. Thank you, Lesley McPhatter, MS, RDN, CSR

I support this bill. This bill provides measures for collecting and evaluating maternal health data to help guide life-saving and quality of life policies in the Commonwealth to improve maternal care, quality, and outcomes for all birthing people.

Comments Document

Regarding HB 169: This bill is urgently needed in our state. While Virginia's Department of Health Review team has worked hard on the issue of reducing maternal mortality, the Journal of the American Medical Association, the March of Dimes and other organizations have found that some states have had more success in recent years in bringing down the disparity between Black mortality and other racial and ethnic groups than Virginia has had to date. In July 2023, JAMA published an article called, "Trends in State Level Maternal Mortality by Racial and Ethnic Groups in the United States", and they found that these deaths were preventable and that Virginia was one of the states with some of the highest disparities in maternal outcomes. Illinois, on the other hand, stands out as an example rapid-paced progress that I hope Virginia will seek to duplicate or otherwise match. I have included a pdf attachment. It is a short document produced by Illinois discussing their approach. I hope the committee will consider language in the bill that will spur efforts to bring down the rate of these entirely preventable deaths a truly urgent matter that a wealthy and resourceful state such as ours should be able to accomplish.

VACo supports sustainable funding for Part C Early Intervention, and supports rates that address the costs of providing these critically important services.

HB177 - Department of Medical Assistance Services; reimbursement rates for Early Intervention Program for Infants and Toddlers with Disabilities; work group; report. The Virginia Association of Community Services Boards (VACSB) is Actively Supporting SB177. For Early Intervention, it is critical that the reimbursement rate is increased on a periodic basis. Rates that are regularly reviewed to ensure adequacy are key to maintaining and developing a strong network of providers for services. Without an adequate rate providers cannot sustain the offering of that service. Part C Early Intervention Programs provide services for infants and toddlers (from birth until age 3) with developmental delays and disabilities. Services provided during the first three years of a child’s life have the greatest impact on that child’s health and developmental trajectory and are critical in eliminating or reducing later disabling conditions and service costs. This results in a decreased need for special education services in the later school years. As well, Early Intervention is part of a continuum of early childhood intervention programs that provide significant return on investment. Every $1 invested in these programs mean an average of $9 saved later through: • Reduced criminal justice involvement • Reduced need for public assistance programs later in life • Fewer children repeating a school year

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Alexandria is a vibrant city based on history, culture, a waterfront and lots of tourism. If Virginia has money and space to build an arena then you have money and space to build new schools. Our school system is deplorable. It’s overcrowded. Think of your citizens before thinking about your quick money grab that eventually leads to an inevitable loss. We don’t want or need an arena. This is pure greed.