 So committee, when Senator Hooker went into the appropriations committee. A couple of things. This is we're going to pick up S120 again and look at it. We never really finished the vote on it. We didn't have an official document because Senator Taranzini wasn't here. So that's actually a good thing. So when Senator Hooker went into appropriations appropriations made some suggestions for changes when they took the money out with they made suggestions that general go over for the consultant. And so that we'll look at that. And then I work over the weekend in communication with Blue Cross and Blue Shield and the FQHCs and hospitals on the PBM language that was is of such concern to to so many folks. And I think that those two differing groups and sides have come to resolution on their differences and so have offered some language how great. That's good. So we'll, so we're going to look at that as well. So as we go through the bill, there was one other suggestion that came to us from Blue Cross and Blue Shield. So we'll, we'll talk about that when we get to it. So just as an overview of where we are with S120. So Jen, I will turn it over to you. Thank you. Jennifer Carby legislative council. So did you want me to put up the, I think we have a new draft. Yes, please. Also need to. After we look at the bill, then we can talk about naming the bill as a numbering the bill and whether it should be a committee bill or not I've heard from members of appropriations and from the secretary's office that it might be cumbersome to put it in as a committee bill and maybe we should stick with what it is. So as S120. So we'll talk about that as well. Sorry, I'm going to pull this over here. All right. Can you see the document? We can see that your name and the number of the document. Okay. Does that mean you can see the whole thing or you can just know we cannot know we you have to click on the link. I know well it's not working. Today, nothing's working right today. Let's try this again. All right, now can you see it. Excellent. All right, so this is the version that is done as a committee bill but as Senator Ryan said, you can have that conversation about how you want it to how you want to proceed with it. So I'll skip through this is just the statement of purpose I summarized the provisions of the bill. So for the most part this looks like what you looked at last week and except there are these changes recommended by the appropriations committee or changes that they're recommending that you make to the task force. This is the task force on affordable accessible healthcare. And so the first thing that they either would have you do or I think they will do if you do not is take the money out they took the money out and put it into the senate budget. So I was reviewing that document. Yesterday did see the money in there I think it should be in the H4 39. That is on the, I think on that calendar. So instead of having a specific dollar amount, which you'll see is struck through later it set would say to the extent that applicable funds are appropriated in the FY 22 budget. The task force through the office of legislative operations shall hire a consultant. And then instead of saying to coordinate the task forces work. It would say to provide technical and research assistance deliver actuarial analyses as needed and support the work of the task force. And then the task force would continue to have the support of her assistance of the legislative offices. So that the language that they've put in there is consistent with the language that's crossed out at the bottom of page seven. Largely so there was this kind of duplicative language in here. Here's where the actual appropriation was so this would come out this whole subsection would come out. Because we've said, you know, to the extent the funds are appropriated and the funds are being appropriated in the big bill. The language here had been the consultant coordinating the activities which is the language you saw struck through an E, and to cover related costs of actuarial analyses research meetings and the per diem compensation and reimbursement for members of the community. So that was just a little drafting this happen. So what I'm going to describe then would be here under assistance, and that would have this consultant providing the technical and research assistance, delivering actuarial analysis is needed and supporting in the work of the task force. You're frozen. Uh oh, rather than just coordinating and with funds being available. Yes. Good. You're, you're, you're freezing a little bit. You're going in and out. Maybe, maybe take your video off while we're going through it. I think there's too much going on. Try it. Let me find my video. Uh oh. It's good now I you know maybe okay something. Yeah, I have been having some internet issues today. Apparently my internet is unstable but maybe it's back. Can you hear me. Yes. Okay, great. So again I was just trying to highlight the differences here. Instead of this language is broader language about coordinating the task forces work. It has this consultant actually providing the technical and research assistance delivering the actuarial analysis as needed and supporting the work of the task force. And the earlier version with the appropriation language at the end here in subsection I, the consultant was doing the coordination, but this money was also to be used to cover related costs of things like research meetings and otherwise. So that is what they are suggesting. You include the reason that that we're looking back at this language again is because of that section toward the end of the bill that you had passed out which I've now struck but just put a little note in to remind us, which was the DFR benchmark plan review. They moved all of that language into the budget. And so they asked that you delete that from your bill and have it ride in the budget. So, and just FYI for everyone. I mean, obviously we, we knew that this would probably happen or could happen. And then I also received a note from Diva, asking that we put the primary care study into the benchmark plan, and it came in a little late. And now the benchmark plan is in the budget so it's not something we can add here. We can add the house or we can, I'll get that message to appropriations to perhaps add primary care visits cost sharing into the benchmark plan. If the committee thinks that would be helpful. I, I think it'd be great actually, but. And that would need to, or would likely be specific to the individual and small group market piece you'd still probably want subsection be which is the remat and care board, and others looking at the impact on the large group including state employees and school employees. Yeah, so and I guess given where we are right now we'll leave it there for now. And then if changes can be made during the H4 39 process or the process that this bill goes through going forward we can maybe that'll get shifted over. Just wanted the heads up on that one so section a you're saying Jen is the one that would go. Yeah, okay. I think it would be this subsection a that is specific to the individual and small group plans are really looking at the qualified health plans, which is the focus of the benchmark plan review so there's the linkage there. Okay. All right. Alrighty. Did you want to go then to the I have not made any changes in parts that you can have the conversation on the pbms but else. I have a copy of the language I sent. I sent you the copy. Can you put that up from from the FQHC and a big Blue Cross Blue Shield dialogue. And you're you're not coming through right now. Jen's gone. Madam chair, maybe we should have Jen not share her screen because that's probably we're going to you're going to do something like that. Jen. Jen. She can't hear me. She's trying to get back here. It's like being in a dark in a black hole out in the universe somewhere. Okay. Yes. Yes. Can you can you see and hear me I switched now we can you froze up. I know I tried. I've been having internet issues today and I tried changing networks and I think it worked, but it booted me off so I had to come back. Okay. So, I don't know where, where we got separated. I can still hear you. You just couldn't hear me. So I have it by email. I mean I have that language and just in an email so I can put it up. Okay. If you want just out of my out of the email document. Basically, what it does is it, it takes away one, the first part of the PBM language, and then it keeps this. I think it's the second part trying to remember each part. Okay. Yes. So it gets rid of, of D one and leaves D two and three so we remember those. Well it puts and so it keeps a study and that's, and then it adds a study study is new. And I actually have a question about the study language I'm just copying and pasting this into a. Okay, so we stand alone document so it doesn't have people's names on it and such. Okay. So, can you see that language. Yes, we can. Great. So, as you can see here, the proposal is to you don't see what is subdivision D one in the version that we have been looking at and it keeps the language of the other two provisions do you want to do to so the PBM shall not require a claim for a drug to include a modifier to indicate that the 340B drug unless the claim is for payment directly or indirectly by Medicaid, or restrict access to a pharmacy network or adjust reimbursement rates based on a pharmacy's participation in a 340B contract pharmacy arrangement. It gets rid of that broader language that was sort of generally about not creating additional requirements or restrictions on a 340B entity on the basis of its participation in the 340B drug discount program. So it's much more specific. It goes right to the specific. Right. And then it would require and I would do this a little differently I wouldn't codify this one time requirement or effective date, but it would have DFR and the Attorney General's Office report to the legislature on January 15 2022 on possible date approaches to the developing issue of pharmaceutical manufacturers ceasing to pay rebates to commercially insured Vermonters this is the piece I had the question on because I'm not sure that they're paying rebates to commercially insured Vermonters personally for drugs dispensed by a 340B pharmacy. It would relate to federal health and human services policy in this area and the financial impact to commercially insured Vermonters and 340B pharmacies of these changes. I think we need a little bit more. I at least need a little bit more clarity on what this, the issue that they're citing of the manufacturers ceasing to pay rebates. I'm trying to say, pay rebates for prescriptions. Well I mean the drugs that are dispensed by 340B pharmacy, the rebates or the drug pricing is realized I think by the pharmacy which is affiliated with this 340B covered entity. I think the people who are working who proposed the language are much more in the weeds on the 340B program than I am. So I'm sure they know what they're talking about I just need to make sure that we're aligned in what we're understanding so I'll leave that to you. And then I'm also not sure this, these provisions shall take effect immediately and expire on December 31, 2022, unless otherwise modified or extended I'm not sure if this is a temporary provision. Then I may, I may change the way it's done altogether we may just put it in session law. I don't so I need to understand more, just having the language by itself is not. Providing me with the full picture of what they're looking for. There was a. Oh, let me just. I got another email late last night. That talked about the date of July 1. Yeah, can I ask you a question who who developed this language because this seems like it does a different thing than what the original language did. Yes, it does. It does. It takes out the first very broad statement. This comes from a dialogue between vase, F the by state primary care and blue cross and blue shield so it was sort of the please go out into the hallway and come up with something that is less controversial on so that this is a compromise. This is compromise language from those folks. And so that's it. So, Madam chair, yeah, can Jen just clarify what this is going to do. Well, as far as the pharmacists are concerned the pharmacies and the drug prices for Vermonters this isn't. I mean when it says on ceasing to pay rebates to commercially insured for monitors. I know that you said you needed to be clear on that and so I need to be clear on it as well. Well, yes, we need to get clarity on that you're absolutely right Senator but the benefit of the 340 b program is to have some access to prescription drugs at prices that are less than other places. So, the, the goal here is to main is to make sure that that continues the first section that was taken out would have been not allowed any action on the part of pbms. This restricts what pbms can do to in a narrower way to access some of the savings and that's really what it's about. Okay, Jen, do you want to to the can you Jen provide a thumbnail sketch of what is happening through the pbms right now and why Utah for example and why Ohio why they're passing the bills that they're passing. I don't actually have that information I mean we, we didn't hear testimony on I don't believe on what problem the language is looking to solve so I'm not able to articulate well yeah we did hear from the hospitals and we heard from the care but their concerns were moderated by concerns from blue cross and blue shield. So the language here simply allows for the for us to make sure that the savings are provided to the 340 b pharmacies and to patients, rather than to the pbms, I think that's really what we're, what we're getting at. Part of the 340 b program for our fqhcs and other pharmacies is to ensure that there are some savings within the pharmaceutical pricing process, and that those savings go to the pharmacies or to the facilities that are 340 be certified. And if you take all the savings away from them then there can not possibly be a benefit to either the pharmacy, the 340 b facility, or to the patient. That's it. Okay, Senator Hardy. Thanks madam chair. I'm feeling a little uncomfortable with this because it seems to me and I don't have the language that Jen just put up. Did you send it to us, Jen, or is I did not it came from an email that the chair had sent to me that I got late yet last night. So, now that the language is up. Can you send that. Nellie you also have a language can you extract the language and post it on our web page. It doesn't seem to be trying to solve the same problem that the other language was trying to solve or at least it seems incongruous with it based. And I'm a little we didn't get that much testimony we got the testimony sort of in as in passing within larger things so I'm, I'm not sure. I'm concerned that if we don't say something about this and have an analysis going forward that all the pharmaceutical savings that that go to 340 b facilities, including pharmacies and patients will be will be under under duress. I understand that I mean I would certainly be concerned about that too but it doesn't. The language that was originally proposed by. It was much broader. It seems to be more about administrative stuff and, and that the benefit managers are requiring all of these sort of administrative hoops to jump through for programs participating in this, and that they were trying to get rid of those administrative hoops. And now the language although I don't have it in front of me seems to be more about. I don't know, payments, maybe. So if you look at what's on page nine of the bill, as we have it before us. So create additional requirements or restrictions on 340 be entity. So it's that could be a pricing or could be rebates I don't know what it is I don't know what that that it could be very it is very broad. Okay, so that. So with that out. Then Nelly is that language up yet. Jen, can you put that language back up that we're looking at. Sure. So you know number three on page nine talks about restrict access to pharmacy network or just reimbursement rates. So that. That's a problem. Okay, so Jen, can you walk us through this one more time. Okay. Okay. Okay. So we fully understand what's here. Sure. It says a pharmacy benefit manager shall not. Require a claim for a drug to include a modifier to indicate that the drug is a 340 be drug. Unless the claim is for payment directly or indirectly by Medicaid. What does it mean to include a modifier to indicate is it just like part of how they bill. It's so in addition to it's something that indicates. Some sort of coding indicator that it's a 340 be drug so it's flagged as being a 340 be drug. Okay. And so I think the impact of this would be so that that the PBM or in short about PBM in this case would be paying claims for drugs without knowledge of whether they are 340 be drugs or not so without without reference to whether the pharmacy acquired them at a reduced cost because they were participating in the 340 be drug pricing program. Okay. Except for Medicaid that information is necessary. And would continue to be included and PBM also could not restrict access to a pharmacy network or adjust reimbursement rates based on a pharmacies participation in a 340 be contract pharmacy arrangement. So again here I think they're looking at getting the regular reimbursement amount and not some reduced amount based on 340 be participation. So it's restrict access to a pharmacy network. What do you know what that would mean. I don't, I don't think I can. Okay. So then we would have. Yes, do you want me to go into the report stuff or do you want you want to discuss these two. I'm trying to get some of the advocates in who were working on this language and invite them in so I've asked Nellie to invite them in to the committee right now so we can have a broader discussion. So, so the. So going back. Restrict access to a pharmacy network, which it would seem to me. That a pharmacy benefit manager. Can't move someone from from one pharmacy to another. So if the pharmacy is a 340 be pharmacy and it might provide lower cost drugs. The PBM may be getting a rebate or some benefit from another pharmacy I don't know exactly how that would work but that could be what is being restricted here not allowing for the pharmacy benefit manager to direct the patient to a specific pharmacy not a 340 be pharmacy. So the benefit to the patient to be at their 340 be pharmacy. Maybe get maybe able to get some benefit from having that patient go to another pharmacy that's kind of that's what I'm reading there, but let's hope that we can get some of these folks in to help us further. So let's go to the report. The report piece is that the Department of Financial Regulation and the Attorney General's Office would report to the General Assembly on January 15 2022 on possible state approaches to the developing issue of pharmaceutical manufacturers ceasing to pay rebates to commercially insured Vermonters for drugs dispensed by 340 be pharmacy. Any update to federal health and human services I think that's the US Department of Health and Human Services policy in this area, and the financial impact to commercially insured Vermonters and 340 be pharmacies of these changes. Okay, so, okay. Is there any question about that one. Yeah, Jen why would the AG's office be what what's their jurisdiction here. I don't know legally legal. I don't know, again, not my language so I don't know. I know I'm sorry. Okay, I don't I don't know what the, I will say was here except perhaps if they're concerned about anti competitive behavior or, or something like that, but I don't know probably and that the AG's office has been very much engaged and looking at drug pricing and gets a report regularly about increased. Cost of drugs, especially for a special specialized drugs. There's a limited amount that we can do in terms of drug drug cost prescription drug costs but the AG's office has been very much engaged in that over time. So that's, I guess, why that one is in there that was my thought when I read it. So now let's know the, I know that the, the, but a PBM may see a rebate, not the individual patient patients don't see the rebate. Let's move. Let's take that one off. And here's my suggestion, I'm going to invite the people in who work together on this. And I keep my little messages. I have no clue what the price, but the price differential is whether that it's based on a PBM and insurance or a 340 be anything that that's not the patient doesn't see that the patient simply sees the copay or the cost overall. So this is about the internal functionings of the 340 be facility and the insurance company and the PBM. What I'm going to suggest is that we invite Helen Laban, Devin Green and Sarah teach out into our committee tomorrow, because we have some time tomorrow. I have deliberately Helen Laban's coming in soon so let's let me see what that message is hang on. So we'll, we'll hold here and whoever can come in to help us this morning, that'll be great. And then if we can't get to closure on this today, we'll take a little bit of time tomorrow and look at it so we can finish our work on h 120. I mean s 120. Thank you. So can we just ask those advocates who are coming in to clarify who this is helping. And yeah, what it's going to do. Yeah, definitely. Yeah. Okay, that'll that that's the primary question, you know, want to make sure the problem with this one is the 340 be program is meant to, to help patient access to prescription drugs at a lower price and through the through the 34 federal 340 be program. But there may be some loopholes that allow for the money to go different places and PBM so passing through. Yeah, you know, it's, it gets to be more and more complicated the further along you go and then you start talking about how do we price prescription drugs and on from there and we haven't looked at that or at least some some of us have the committee hasn't seen that recently so we may want to pick that one up at some point. So, Madam chair, are we doing tomorrow that the joint session Thursday. Oh, it's Thursday. Oh, I had in my mind that it was tomorrow with judiciary Thursday. I deliberately put a day between today and that one just so we could do anything we needed to on the bills that went to appropriations, and on Thursday while we're discussing it is a joint meeting with the Judiciary Committee on a bill. H 225 on the on buprenort low quantities of buprenorphine. And so we'll, I've been working with getting testimony for that and Senator Sears has been working getting testimony for that so we'll have that day together. But for this one. Jen, I think there's another section that we should look at and that is a an ask from the insurance companies actually from Sarah Sarah teach out from blue cross and blue shield about the administrative expenses report indicating that it isn't it's an unnecessary request so when she comes in will ask her to go through that with us as well I just just this morning received an email from her about that. So committee let's take a break until 11 o'clock. And we'll see if Helen laban joins us or if Devon green or Sarah teach out. Join us and then we'll pick up at 11, where we are right now. Okay.