►
Description
House Insurance Committee- February 15, 2022- House Hearing Room 1
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
B
A
A
B
Thank
you,
mr
chairman
committee
house,
bill
1925
is
a
model
piece
of
legislation
that
is
brought
by
the
national
association
of
insurance
commissioners
and
the
u.s
travel
insurance
association.
There
was
some
regulatory
uncertainty
at
the
national
level.
What
this
bill
seeks
to
do
is
create
some
uniformity
and
consistency.
B
There
are
18
been
18
states
that
have
already
adopted
it
and
there's
a
lot
of
states
this
year
that
are
taking
up
this
piece
of
legislation.
It's
a
great
piece
of
legislation.
I
doubt
any
of
you
will
have
any
questions
about
it,
but
if
you
do,
I
will
take
any
questions.
Mr
chairman,.
B
Thank
you,
mr
chairman,
so
this
defines
a
lot
of
industry
terms
in
a
in
a
uniform
way.
It
allows
travel
products
to
continue
to
be
offered
in
a
manner
that
provides
kind
of
seamless.
Customer
experience
clarifies
permissible
sales
practices.
B
It
prohibits
the
practice
of
opt-out
sales
and
opt-out
cells
is
which
a
person
is
automatically
sold.
The
product
or
the
product
is
travel,
insurance
is
added
automatically
and
you
have
to
notice
it
and
opt
for
it
to
be
taken
off.
It
prohibits
that
practice
creates
more
clear
consumer
disclosures
and
various
things
like
that.
Mr
chairman,.
C
Thank
you,
mr
chairman,
could
you
name
those
18
states,
please
that
in
alphabetical
order
that
you
said
are
already
doing
a
population?
Yes,.
A
Why
shaman
rudder?
Did
you
have
a
question
members?
It
seems
that
everybody
must
have
watched
the
subcommittee
presentation
and
that's
good
preparation
because
it
was
discussed.
Well.
Are
we
ready
for
the
questions
without
without
objection?
We
are
voting
on
house
bill
1925
all
in
favor,
please
say:
aye
opposed
the
bill.
Moves
on
to
devops
thank.
A
D
You,
mr
chairman,
I
just
wanted
to
recognize
someone
in
the
audience
a
former
member.
He
walks
around
with
a
smile
on
his
face
all
the
time
when
he
was
member
of
this
body.
I
don't
remember
him
smiling
much,
but
former
member
gerald
mccormick
welcome
gerald.
A
A
Gentlemen,
welcome
you
know
the
routine
and
kindly
enlighten
us
for
where
you
stand.
It
has
been
a
busy
and
a
controversial
time,
and
I
think
you
attended
the
meetings
last
week
and
you
know
the
issues
that
were
brought
forth.
Please
list
them
and
your
responses
to
it
and
we
look
forward
to
it.
Thank
you.
E
Thank
you
chairman,
madam
vice,
chair
and
committee,
for
is
this.
So
can
you
hear
me
thank
you
for
giving
us
opportunity
to
come
in
today
and
present?
E
So
sorry,
sorry,
chairman
bill
huddleston
assistant,
commissioner,
for
insurance
at
the
department
of
commerce
and
insurance
and.
F
Michael
driver
general
counsel,
with
the
department
of
commerce
and
insurance.
Thank
you.
A
Just
to
simplify
what
seems
to
be
a
complex
matter,
we
do
have
a
slide
on
the
screen
that
shows
the
relationship
between
the
drug
manufacturer
and
the
pharmacies
that
dispense
the
drugs
to
the
patients
and
in
between,
of
course,
is
the
health
plan
that
pays
for
it
and
the
pharmacy
benefit
managers
who
control
the
formulary,
as
well
as
the
pricing
and
manage
the
drugs
that
are
used
and
how
they
are.
It's
a
complex
relationship
with
the
rebates
and
other
issues
involved.
But
this
is
the
general
outline
go
ahead
and
proceed.
E
Thank
you
chairman.
I'm
glad
that's
your
slide.
I
was
that's
more
words
and
arrows
than
I
would
have
used,
but
it,
I
think,
that's
kind
of
where
I
would
have
started.
When
we
talk
about
the
pbm
issue.
It
does
get
fairly
complicated
and
complex,
pretty
quickly
it,
and-
and
it's
not
just
that
way
here
in
tennessee.
E
Many
states
are
facing
that
issue
right
now,
but
I
I
think
I
would
also
like
to
kind
of
start
off
by
saying
that
public
chapter
569,
it
greatly
increased
the
scope
of
regulatory
requirements
for
for
pbms
that
the
department
has
oversight
over
I'm
going
to
kind
of
go
through
a
timeline
just
since
july
1,
when
the
law
is
in
effect
and
talk
about
some
of
the
challenges
and
some
of
the
substance
substantive
thing,
actions
that
we've
taken
to
to
to
to
to
put
the
law
into
place,
the
the
first,
the
first
thing
in
july,
the
first
week
of
july,
we
had
some.
E
We
had
a
bulletin
that
we
put
out.
That
was
addressing
an
issue
brought
up
about.
Does
this
public
chapter
apply
to
erisa
plans?
We
stated
in
that
bulletin
that
erisa
plans
were
included
and
this
did
apply
to
them.
We
also
gave
direction
in
that
bulletin
about
how
to
submit
appeals
processes
to
the
pbms.
E
The
the
public
chapter
has
and
I'll
get
more
into
this
in
a
bit,
but
there's
an
exception
that
appeals
can
be
submitted
to
the
department
and
approved
for
the
pbm
and
that's
to
accept
exempt
them
from
paying
reimbursing
at
actual
cost,
so
I'll
get
to
that
a
little
bit
more
in
depth.
But
at
that
point
we
also
began
intake
from
complaints
on
the
matter
on
the
issues
and
that
that
may
come
up
from
this
public
chapter
and
we
started
that
with
our
mediation
process.
E
This
is
where
a
little
bit
of
the
cpa
side
of
me
comes
out.
I'm
I'm
looking
at
the
data
and
a
couple
of
interesting
things
that
showed
up.
There
was
out
of
the
439
complaints
that
we
have.
E
360
of
those
80
was
could
be
attributed
to
the
top
three
pbms.
We
had
complaints
against
outside
of
that
12
of
the
pbms
only
had
one
complaint
lodged
against
them.
I
just
think
those
are
some
interesting
pieces
of
the
data,
so
we
started
taking
in
those
appeals
processes
and
reviewing
those,
and
that
was
I
guess
september
1
was
when
we
told
we
notified
the
pbms
that
they
had
to
have
their
appeals
processes
turned
into
us
if
they
wanted
to
use
that
as
an
exception.
E
E
E
That
led
to
several
discussions
internally
and
also
externally,
but
we
had.
We
realized
that
there
was
something
that
was
obviously
not
clear
about
what
needed
to
be
in
those
processes
for
approval
which
led
to
a
bulletin
number
two
that
we
put
out
in
december.
I
think
on
the
22nd
of
december
that
bulletin
outlined
the
except
the
exception
to
paying
or
reimbursing
an
actual
cost,
and
it
listed
in
the
bulletin
items
that
we
would
look
for
to
to
make
the
appeals
process
approvable.
E
I
think
10
approvals
thus
far
and
there's
more
in
the
pipeline,
but
some
of
those
issues
that
we're
talking
about
that
the
challenges
that
we
ran
into
it
should
also
be
noted
that,
as
we've
tried
to
implement
and
and
made
a
effort
to
implement
that,
we
are
also
working
with
members
of
the
general
assembly
on
a
couple
of
bills
to
clean
some
of
this
up
and
and
and
clarify.
E
A
Legislation
said
that
pharmacies
will
not
be
paid
under
their
cost
and
when
that
happened
there
was
an
appeal
process
that
was
supposed
to
be
in
place
and
what
you're
saying
is
it
was
in
place
and
it
was
submitted
to
your
department
for
approval
and
the
ones
that
you
looked
at.
None
of
them
met
the
criteria,
tell
us
what
the
criteria
were
and
then
what
corrective
action
did
you
propose?
Did
you
correct
the
matter
that
pharmacies
will
not
be
underpaid.
E
Yes,
chairman
that
we
we
so
there
were
35
appeals
processes
submitted
all
35
denied
the
the
bulletin
number
two
that
we
put
out
in
december
list
and
and
and
this
was
directly
to
address
what
we
found
as
discrepancies
in
those
original
processes,
and
it
mostly
related
back
to
timing
and
notice
requirements
and
actually
noting
a
secure
website
for
the
process
to
to
use.
E
But
I
can
actually,
if
you
don't
mind
I'll,
just
read
off
of
the
bulletin
the
those
requirements.
E
The
timing
and
notice
requirements
were
that
the
pharmacy
must
file
its
appeal
within
seven
business
days
of
its
submission
of
initial
claim
for
reimbursement
for
the
drug
or
medical
product
or
device
the
product.
I'm
sorry,
the
pharmacy
benefit
manager
or
covered
entity
must
make
a
final
determination.
Resolving
the
pharmacy's
appeal
within
seven
business
days
of
the
pharmacy
benefits
manager
or
covered
entities.
E
So
all
of
the
processors
we
got
did
not
have
those
in
it
in
the
and
what
they
submitted
well.
A
E
E
A
Coming
back
to
the
basics,
mr
hudson,
so
did
it
help
the
pharmacy
that
was
getting
underpaid.
E
E
A
E
So
the
and
also
in
bulletin
number
two
we
we
we
stated
that
the
the
law
says
or
the
public
chapter
doesn't
it.
It
says
that
if
the
appeals
process
is
in
place
that
exempts
from
reimbursing
at
actual
cost.
A
I'm
still
not
getting
it
in
the
sense
that
did
the
payment
to
the
pharmacy,
improve.
A
I
I
think,
you've
in
a
way
you've
helped
us
understand
the
question
if
it
had
improved.
We
will
not
be
here
today.
So
that's
why
we're
here,
chairman
smith,
you're
recognized.
G
Thank
you
chairman,
and
thank
you,
mr
huddleston
and
folks.
So
let
me
just
kind
of
revisit
some
of
your
comments.
You
mentioned
that
of
the
30
some
odd
pbms
that
three
were
the
had
the
disproportionate
share
of
the
of
the
complaints
filed
and,
as
we
heard
from
testimony
last
week
in
this
state,
there
are
only
three
major
pbms.
E
G
G
Jim
smith-
and
I
want
to
follow
up
with
our
chairman-
I
think
what
he's
saying
is:
if
there
is
a
process
that
is
supposed
to
determine
remedy
and
that
remedy
is
to
ensure
that
a
pharmacy
does
not
to
be
reimbursed
at
a
level
below
acquisition
cost.
The
answer
is
pretty.
I
mean,
as
my
deputy
speaker
right
here
is
telling
me,
you
know
constantly.
The
answer
is
yes,
or
no
are
people
being
paid
below
that
equity
cost
after
er?
G
G
As
as
our
chairman
was
trying
to
put
into
the
record,
is
we
still
don't
have
a
process?
That's
working
is
what
I'm
hearing
relative
to
this
to
this
body
and
let
me
kind
of
go
to
the
the
wonderful
graphic
that
our
chairman
has
put
together.
You
know,
I
really.
G
I
think
this
is
a
terrific
visual
and
I
just
want
to
bring
attention
to
a
couple
of
things
here
that
that
you
know
this
would
this
is
this
would
work
if
this
is
what
happened,
but
when
you
take
the
health
plan
and
the
pharmacy
benefit
manager
and
the
pharmacy,
and
you
put
them
in
one
bubble
and
they're
self-contained
in
a
closed
system,
then
guess
what
there's?
G
No
transparency,
there's
little
accountability,
the
fiduciary
firewall
is,
is
abysmal
and
doesn't
exist,
and
this
body
can't
get
answers
and
and
it's
frustrating
so
I
would
like
for
you,
on
behalf
of
the
department,
to
speak
to
the
fact
that
you
know
what
we
have
is
a
vertical
alignment
of
these
very
profitable
entities,
and-
and
if
this
were,
as
my
colleague
I
know,
chairman
supiki
likes
to
say,
if
this
were
another
business,
we
would
be
breaking
up
the
monopoly.
G
A
H
Gift
that
keeps
giving,
mr
chairman,
I
am
not
as
adept
as
most
of
my
colleagues
here
in
insurance,
but
I
have
common
sense.
H
You
know
my
dad
told
me
a
story
a
long
time
ago.
The
art
of
doing
nothing
is
appearing
like
you're
doing
something
your
department's
job
is
to
enforce
the
law.
A
statement
was
just
made
that
there
are
pbms
not
paying
the
pharmacies
for
their
true
cost.
What
the
cost
is
the
acquisition
cost
is,
I
think
the
word
that's
a
violation
of
the
law.
H
H
E
We
so
we
we
haven't
done
nothing.
We
have
put
a
lot
of
hours
and
a
lot
of
work
into
evidence
by
the
bulletins
that
we
put
out
evidenced
by
the
439
complaints
that
we
took
in
and
and
went
through
the
mediation
process.
E
Some
of
those
things
are
still
in
play
and
being
looked
at
reviewed
as
far
as
the
reimbursement
at
less
than
cost
being.
There
are
in
the
public
chapter
those
exceptions
that
are
outlined
in
the
bulletin
and
that's
part
of
the
law
too,
that
we've
that
we've
taken
action
to
put
into
place
getting
those
appeals
processes
turned
in
and
reviewing
thoroughly
at
a
level.
That
is
not
just
you
know,
signing
that
we
approved
but
actually
actually
vetting
the
approval
process
that
it's
in
accordance
with
what
the
chapter
calls
for.
A
I
want
to
make
sure
that
my
statements
are
correct.
Is
that
we'll
get
a
legal
opinion
on
it?.
A
While
we're
looking
that
up
so
that
the
when
a
pharmacy
complains
that
they
were
underpaid,
they
had
appeals
process.
Your
job
for
the
department
was
to
make
sure
the
appeals
process
is
not
only
timely
but
also
adequate,
but
yet
in
that
evaluation,
that
the
payment
to
the
pharmacies
did
not
get
improved
well,.
B
Zach
brown
legal
services,
the
section
of
code
that
does
describe
the
appeals
process
it
it
aligns
with
with
what
chairman
kumar
said.
It
doesn't
mention
penalties
for
for
underpayment.
It
does
describe
an
appeals
process.
A
Thank
you.
Thank
you.
We
appreciate
it.
The
german
speaking,
sorry
to
interrupt
your
flow,
but
please
go
ahead.
H
As
chairman
smith
reiterated
about
breaking
up
monopolies
here,
I
can
look
at.
I
can
look
at
what's
behind
you
on
the
board
and
you
can
see
a
choke
point
in
this
whole
thing.
Is
the
pharmacy
benefit
manager
when
you
have
other
entities
controlling
those
and
controlling
pharmacies
and
controlling
drug
manufacturers,
you
pretty
much
have
a
definition
of
a
monopoly.
H
H
So
no
cease
and
desist.
I'm
sorry,
mr
chairman,
am
I
right?
Am
I
okay
to
speak?
Go
ahead?
Thank
you,
so
no
cease
and
desist.
So
can
you
understand
the
conundrum
we're
in
right
now
is
we're
getting
testimony
from
independent
pharmacies
saying
that
the
pharmacy
benefit
managers
are
steering
their
patients
away
to
pharmacies
that
are
controlled
by
other
entities?
E
In
the
complaints
that
we've
received
that
steering
that
that
are
related
to
steering
or
called
steering
by
the
complainant,
it's
it's
a
wide
range.
So
you,
you
may
see
something
that
is
a
flyer
or
an
advertisement
in
the
mail
or
something
that
was
printed
on
a
card
which
we
would
we
don't
really.
E
I
don't
that's
hard
to
call
that
steering
in
some
cases,
so
some
of
that,
but
there's
a
wide
range
from
that
to
the
other
end,
which
probably
is-
and
we
are-
there-
are
some
of
those
that
we
are
looking
at
right
now
reviewing
to
to
see
if
we
can,
if
that,
if
they
actually
are,
it
takes
a
little
bit
more
in-depth
analysis
than
just
seeing.
Well,
that's
not
you
know
the
ones
that
aren't,
but
we
there
are
some
of
those
that
were
that
we're
reviewing
in
legal
right
now.
H
James,
thank
so,
and
you
can.
These
are
my
last
two
questions
for
you,
because
I'm
sure
people
are
going
to
want
to
talk
to
you
too,
since
this
bill,
since
this
has
become
law,
439
complaints,
okay
out
of
those
439
complaints,
the
ones
that
you
may
your
department
may
have
looked
at
as
a
steering
issue
or
something
you
stated
that
you've
given
no
cease
and
desist
orders
for
that
trade
practice.
E
E
So
you
can
imagine
we're
moving
from
an
application
and
an
annual
well
actually
a
biennial
fee,
which
is
pretty
much
administrative
work,
two
something
that
is
way
more
in
depth,
such
as
reimbursement
or
steering,
and
so
there
it
the
department
being
equipped
to
really
have
the
knowledge
to
go
about,
addressing
some
of
that
that
that
did
take
a
little
bit
of
time
to
understand
and
implement
and
as
also
evidenced
by
the
bulletins,
communicating
with
the
licensee
those
expectations
that
took
a
little
bit
of
time
as
well.
I
Thank
you,
mr
chairman,
like
representative
piggy
said,
I'm
a
novice
to
this,
I'm
not
in
the
medical
industry,
but
I
like
to
observe
and
watch
things
and
occasionally
come
up
with
ideas
and
solutions
that
most
people
in
the
industry
don't
think
of
they're,
not
always
practical.
I
The
one
thing
I've
seen
here
is:
we
have
four
groups.
We
have
doctors
and
consumers,
we
have
insurance
companies
and
pbms
which
the
insurance
companies
control
and
pay,
and
the
pharmacies
and
the
drug
companies,
and
sometimes
we
have
insurance,
pbms
pharmacies
and
drug
companies
working
together
or
in
partnerships
at
clinics
and
other
things.
I
It
seems
like
to
me
that,
as
everyone
here
has
pointed
out,
that
pbms
are
the
problem
both
to
you
and
to
consumer
and
in
some
cases
even
to
the
insurance
and
pharmacies
and
etc,
seems
like
to
me.
The
only
solution
to
this
is
to
eliminate
the
pbms
and
have
the
state
take
over
and
form
an
agency
to
become
the
pbms
so
that
we
have
the
state
looking
out
after
the
interests
of
the
consumers.
E
I
E
I
think
I
can
speak
for
the
department
by
saying
we're
glad
to
work
with
the
members
on
ideas
always
glad
to
do
that.
I'm
not
sure
if
you
know
how
that
lines
up
growing
state
government
or
growing
government
at
all,
I'm
not
sure
how
that
I
don't.
I
don't
know
that
that
fits
in
philosophically
with
the
administration's
standpoint,
but
I'm
glad
to
run
that
by
and
see
see
what
my
boss
says
and
always
glad
to
work
with
you
guys.
However,
we
can.
A
I
J
Yeah,
thank
you,
mr
chairman.
You
know,
let
me
start
by
saying
I
I'm
no
fan
of
pbms
in
in
my
business
as
a
benefits
broker.
Probably
80
of
the
groups
I
lose
are
because
of
the
pbm
you
know,
and
their
failure
to
provide
customer
service.
So
you
know
the
people
he
spoke
of.
You
have
the
consumer,
then
you
have
the
advocate
for
the
consumer,
which
is
the
broker
dealing
with
the
insurance
company
and
the
pbm.
J
J
Okay,
so
the
big
three
have
80
market
share,
so
it
you
know,
makes
sense
that
80
of
the
complaints
are
against
them.
So
that
makes
sense.
So
then
I
think
I
heard
you
say:
well,
let's,
let's
ask
something
else,
so
we
we
dumped
459
complaints
from
the
legislation
we
passed
here.
How
many
additional
staff
members
did
that
legislation
provide
you
to
do
this
additional
service.
J
J
Then
I
heard
you
maybe
say
that
you
are
working
with
a
couple
of
legislators
currently
to
fix
some
of
the
legislation
that
we
passed
last
year
because
it
may
not
have
given
proper
due
process
on
these
complaints
against
these
pbms.
So
there's
no
sense
in
you
doing
something
and
rendering
some
judgment
against
the
pbm.
E
The
we
are
working
with
giving
some
feedback
to
members
of
the
of
this
body
to
address
some
of
those
issues
and
about
the
court
throwing
out
anything.
I
I
don't
know
about
that,
but
I
would
if
your
question
was
about
our
work
with
members.
We
have
been
doing
it.
J
J
I
think
it
goes
back
to
the
pbms
again
and
we
need
to
work
with
the
department
to
make
sure
we've,
given
them
one
the
tools
and
two,
the
necessary
legislation,
to
do
what
we
want
them
to
do.
So
I
think
we
need
to
go
back
to
the
drawing
board
and
fix
what
we
sent
them
and
give
them
some
help.
If
we're
gonna
ask
somebody
to
do
more
work,
we
may
need
to
put
some
more
workers
on
the
job.
Thank
you.
K
K
There
may
be
some
some
language
within
the
legislation
that
we
need
to
come
back
and
improve,
and
mr
huddleston
will
certainly
take
any
suggestions.
As
you
have
heard,
the
concerns
from
many
committee
members
who
have
heard
from
many
constituents
that
those
concerns
are
real
and
it's
all
about
fairness
in
in
the
process
that
we
want
to
continue.
K
I
think
that
we've
got
house
bill,
2661
and
house
bill
2660
in
particular
two
pieces
of
legislation
that
I
will
put
on
the
record
that
we
are
currently
working
on
to
to
try
to
come
up
with
these
corrective
measures.
So
I
look
forward
to
to
working
with
you
and
the
sponsors
of
those
legislations
one,
and
I
think
both
will
eventually
be
on
this
committee,
that
that
will
come
up
with
corrective
actions
for
that.
Thank
you,
mr
chairman.
Thank.
L
L
Just
for
the
record.
Our
whole
medical
system,
these
days
is
carved
up
into
multiple
different
groups.
They
all
have
their
places
carved
into
the
law
and
because
of
that,
it
has
gotten
so
opaque.
The
consumer,
at
the
end
of
the
day,
has
no
idea
what
they're
paying
for,
except
to
be
told
when
they
ask
what
something
cost
at
a
doctor's
office.
Oh,
it's
free.
Your
insurance
takes
care
of
it.
That's
my
comment.
Sorry,
I'm
off
the
soapbox.
Now
to
my
question.
L
My
colleague
from
murray
earlier
was
asking
you
about
some
of
the
things
that
you've
seen
in
your
almost
year.
Now
of
doing
this,
it
sounded
to
me,
like
kind
of
your
answer:
was
there
we're
on
a
learning
curve?
Can
you
elaborate?
What
have
you
seen?
We've
all
seen
the
charts
we've
most
of
us
been
lobbied
by
this
group
or
that
what
have
you
learned
in
nine
months?
That
would
be
more
revealing
to
us,
as
a
committee,
more
helpful
to
us
solving
this
going
forward.
Thank
you.
E
Thanks
for
the
question
representative,
it
has
been
a
pretty
insightful
nine
months.
I've
we've
learned
from
many
different
we've
talked
with
a
lot
of
a
lot
of
different
parties
on
this.
We've
talked
with
other
states,
the
regulators
from
other
states
that
have
new
pbm
laws
and
how
they're
going
about
enforcing
it.
So
we've
learned
about
some
of
the
resources
that
they
use
or
that
they
have
to
have
to
to
make
this
work.
E
E
So
I've
learned
about
some
other
from
from
the
perspective
of
the
pharmacist,
we've
learned
about
that.
I
guess
we've
worked
with
naic
we've
national
association
of
insurance
commissioners.
E
Part
of
the
talking
points
with
our
congressional
delegation
was
ex.
You
know:
expansion
of
state
oversight
over
pbms,
so
I
mean
that's
something
that
we
talked
about.
I
mean
there's
just
there's
a
lot.
I
think
the
the
the
biggest
thing
is,
I
kind
of
look
at
things
like
you
know,
just
I
don't
get
into
the
details
so
much,
but
I
see
the
data
in
terms
of
what
the
biggest
issues
are
for
them.
So
we've
have.
E
We
have
data
now
that
shows
about
half
of
that
data
was
saying
that
the
or
half
of
the
complaints
were
about
steering
issues
and
half
of
it
was
about
reimbursement
issues.
So
it's
it's
helpful
to
know
kind
of
which
way
to
look
there.
I
guess
really
the
the
thing
that
I
I
think
I'm
walking
away
from
with
from
the
past
few
months
is
just.
E
A
C
Thank
you,
mr
chairman.
Thank
you
all
for
coming
out
today.
I
think
a
lot
of
the
problem
we
touched
on
a
little
while
ago,
too,
was
dealing
with
erisa
plans
that
and
the
the
bill
that
we
passed
is
kind
of
in
a
conflict
with
what
the
federal
government
is
doing.
So
could
you
talk
a
little
bit
more
about
that?
Do
you
think
that
the
the
fix
that's
coming
down?
The
road
is
going
to
going
to
take
care
of
that
part
of
it.
E
Sure,
thank
you
chairman
sure.
The
erisa
has
has
that's
another
good
point.
It's
been
a
learning
curve
on
that.
Prior
to
this
public
chapter,
we
we
that
that
was
outside
of
our
scope.
Erisa
was
outside
of
our
scope.
You
know,
I've
said
before
we
just
dealt
with
fully
insured
plans,
so
the
the
erisa
issue.
E
I'm
not
sure
if
I'm
not
sure
where
the
fix
is
there,
it's
been
complicated
and
messed
up
for
so
long
for
it
from
our
perspective
that
it's
just
hard
to
to
know
how
that
how
that's
gonna
shake
out,
but
I
do
know
that
it
seems
like
court
case
after
court
case.
We
hear
well
recently
any
anyhow
that
the
state
should
have
that
regulatory
authority
over
over
certain
things.
E
So
I
don't
know
if
it's
addressed
through
that
or
if
there's
some
other
thing
at
the
federal
level
that
that
could
address
it.
C
Okay,
because
because
I
know
it's
a
federal
when,
when
the
risk
wrist
law
came
out
years
ago,
and
it's
supposed
to
cover
every
every
state,
so
I
I
just
wondered
you
know
if,
if
anything
that
we
did
at
the
state
level
would
be
in
conflict
with
that,
and
then
if
there
was
some
kind
of
supremacy
clause
or
something
dealing
with
the
federal
level
over
the
state
level.
And
so
I
guess,
will
that
be
determined
by
the
court
case.
You're
talking
about
mr.
F
Mr
driver,
if
I
am
mr
chairman,
mr
sherman,
so
yes,
generally
speaking,
erisa
preems
any
state
laws
that
relate
to
an
orisa
plan.
Now
I
say
that,
but
that's
a
very
complicated
analysis.
That's
been
refined
over
a
couple
of
recent
court
cases.
First,
the
gobe
case
subsequently
the
rutledge
case
and
then
there's
another
case
coming
up
in
the
circuits,
which
is
the
webby
case,
and
so
I
don't
think
it
is.
F
You
know
the
the
orisa
area
is
a
a
highly
litigated,
highly
contentious
area
as
to
exactly
what
the
scope
of
orisa
is.
Obviously,
the
federal
constitution
provides
for
the
supremacy
costs
that
the
you
know,
federal
law
is
the
law
of
the
land.
However,
the
scope
of
that
conflict
and
the
scope
of
a
conflict
between
any
given
state
law
and
orisa
itself,
because
of
that
complicated
analysis
has
to
be
reviewed
on
the
facts
of
that
individual
law,
its
language
and
a
determination
made.
F
And
ultimately
you
know
it
is
possible
that
that
that
could
end
up
in
in
litigation.
As
previously
stated
by
assistant
commissioner
huddleston,
the
department
previously
issued
a
bulletin
that
the
plain
language
of
public
chapter,
569
as
it
was
drafted,
does
cover
those
arrested
plans.
Okay,
all
right.
D
Thank
you,
mr
chairman,
mr
huddleston,
thank
you
for
being
with
us
today
and
when
we
heard
from
the
pharmacist,
I
think
one
thing
that
we
heard
over
and
over
again
is
you
know
after
we
passed
the
law
that
we
passed,
there's
been
no
change,
and
I
think
what
I've
we've
heard
from
you
today
is
you've
taken
on
this
additional
responsibility
with
no
additional
staff.
A
Thank
you.
Thank
you
for
bringing
that
perspective.
Certainly,
the
department
needs
the
resources,
along
with
the
knowledge,
to
enforce
complex
legislation,
and
I
think
mr
hulson,
mr
driver
they've,
given
a
sincere
presentation
and
they
are
sincere
in
their
efforts,
and
I
think
the
legislature
will
also
do
our
part
and
ultimately
to
serve
our
consumers,
because
really
people
should
not
getting
be
getting
paid
less
than
the
cost
of
their
business.
We
are
just
about
finished,
but
as
a
courtesy,
german
smith,
kindly
take
30
seconds,
I
will.
G
Just
real
quickly,
in
current
code,
even
before
speaker
sexton's
bill
that
we
all
supported
last
year,
isn't
there
a
provision
that
pbms
are
licensed
and
they
pay
a
fine
for
registry
in
the
state
of
tennessee.
G
A
Thank
you.
Thank
you
for
your
perspective,
members
that
we
need
to
move
on
to
our
next
presentation.
Once
again,
mr
harrelson
and
mr
driver.
Thank
you
for
coming.
Thank
you,
mr
chairman.
I
appreciate.
E
A
And
that
comes
from
the
pbm
industry
themselves,
kindly
introduce
yourself
and
tell
us
your
perspective
on
this
whole
matter,
why
all
these
people
are
upset
with
you.
M
Thank
you
for
the
opportunity,
mr
chairman,
and
if
and
if
we
can,
I
would
I
kind
of
wanted
to
keep
your
slide
up
there
just
for
a
second
and
address
some
of
those
questions.
A
He
wants
that
slide
back.
Oh
there
you
go.
M
Thank
you
very
much
trey
moore
local
council
on
behalf
of
the
pharmaceutical
care
management
association
with
me,
michael
powers,
he's
the
senior
director
for
state
affairs
at
pcma
and
he's
he's
prepared
sort
of
pbm
101
presentation
per
year,
request
chairman,
but
if
I
could,
since
we're
sort
of
responding
a
little
bit
to
some
of
the
testimony
before
and
some
of
the
questions
I
want
to
just
hit
on
a
couple
of
highlights,
I
think
the
slide
behind
me
is
a
pretty
good.
I
say
starting
point
in
understanding
the
supply
chain.
M
I
I
would
point
out
a
couple
of
missing
pieces
that
that
are
critical
and
one
just
you
know
down
there
at
the
bottom,
under
pharmacy,
business
benefit
mana
manager.
The
difference
between
these
payments
is
called
the
spread.
The
bill
last
year
eliminated
that
so
that
you
know,
and
and
and
that's
good
law
on
the
books.
There's
should
not
be
a
scenario
where,
where
a
pbm
in
tennessee
under
in
the
fully
insured
market
is,
is
using
spread
pricing.
M
Second,
there's
been
a
lot
of
conversation
about
the
size
of
of
the
big
three
quote-unquote
big
three
pbms.
You
know
80
percent
of
the
market
and
I
will
not
deny
that
they
are
very
large
companies.
I
think
what
gets
lost
a
little
bit
in
the
conversation
is
that
the
pbm's
main
counter
part
at
the
negotiating
table
is
what's
called
a
psao,
a
pharmacy
services,
administrative
organization.
M
That
is
a
name
I
would
choose.
If
I
didn't
want
anybody
to
talk
about
it
ever,
but
it's
a
psao
is
easier
to
to
explain
it
is.
It
is
an
entity
that
basically
groups
pharmacies,
chain
and
independence
into
buying
groups,
then
they
negotiate
those
terms
with
the
pbm.
So
what
they're
going
to
get
reimbursed?
M
You
know
what
the
reimbursement
terms
are.
What
the
audit
terms
are,
everything
that
would
go
into
a
pharmacy
contract
with
a
pbm
is
negotiated
by
a
psao
in
four
out
of
five
cases,
so
over
80
percent
of
the
independent
pharmacy
market,
utilizes
a
psa
and
they
charge
the
psa
with
with
negotiating
with
pbm.
So
they
take
that
off
their
plate.
Mainly
it's
practical
right.
They
don't
want
to
negotiate
with
60
different
pbms.
They
don't
negotiate
with
the
big
three
pbns,
so
they
go
to
the
psaos
and
they
say
we
want
to
get.
You
know
we'll.
M
Let
you
negotiate
on
our
behalf.
You
get
us
the
best
deal.
You
can
because
you've
got
bigger
buying
power
than
we
do
right
and
and
to
represent
lafferty's
part.
It's
it's
it's
about
scale
in
retail,
right
how
much
you
can
source,
how
you
source
and
how
you
how
you
sell,
but
I
think
it's
worth
noting
that
when
we
talk
about
psas,
the
biggest
psaos
in
the
country
are
owed
are
owned
by
the
largest,
the
three
largest
wholesalers
and
a
slide.
M
I
saw
this
morning
your
big
three
wholesalers,
which,
as
I
said,
are
your
counterparts
to
the
pbms
and
their
function
as
a
psao
controlled
95
percent
of
the
distribution
market,
95
right,
so
that
is
who
pbms
are
going
against
in
negotiating
their
rates
for
their
customers
to
to
representative
smith's
point
on
health
plan.
Their
health
plan
would
apply
to
a
health
insurer
in
the
individual
small
group
market
and
it
would
apply
to
government
plans
and
it
would
apply
to
self-funded
erisa
exempt
plans.
M
A
A
A
You
will
negotiate
with
the
manufacturers
or
with
the
psaos
about
the
pricing
of
those
drugs,
and
you
will
negotiate
also
with
the
pharmacies
about
what
you're
going
to
pay
them
so
you're,
a
controlling
center
that
will
work,
take
the
money
from
the
insurance
company
or
the
payer
disperse
it
to
purchase
them
the
goods
and,
of
course,
dis
disperse
it
to
the
pharmacies
who
will
dispense
the
goods
in
between.
Of
course,
certainly
you
are
in
business
to
make
a
profit
and
you'll
make
a
profit,
and
there
are
some
matters
like
rebates
and
other
things
involved.
A
Also.
The
transparency
where
the
prices
that
you
pay
for
the
drugs
are
not
revealed
and
that's
understandable,
given
the
business
model.
But,
coming
back
to
you
shook
your
head
when
I
said
that
you
choose
the
drugs
that
are
placed
in
the
formulary,
go
ahead
and
briefly
clarify
that.
M
So
formulary
management
is
a
part
of
the
service
that
is
offered.
That
said,
the
health
plan,
in
every
case
before
a
formulary
is
set,
gets
to
decide,
gets
the
ultimate
say
so
those
decisions
are
made
in
concert
with
a
pbm
they're,
also
made
in
concert
with
a
pharmacy
benefit
consultant,
which
is
not
us
that
a
large,
a
large
plan
might
hire
to
help
them
negotiate
with
the
pbm
on
things
like
a
formulary
but
the
old.
M
But
ultimately
it's
just
like
an
rfp
right,
which
I'm
trying
to
put
it
into
terms,
that's
easier
sort
of
to
think
about
right,
and
so
what
is
an
rfp?
A
request
for
proposal?
Just
like
a
state
contract
right-
and
you
know,
the
the
health
plan
basically
dictates
what
what
services
they
want
from
the
pbm,
whether
how
far
that
management
process
goes.
They
the
health
plan,
determines
the
coverage.
The
health
plan
deter
and
the
employer
gets
determined.
M
A
And
once
again,
you
have
cso
and
function
in
purchasing
in
dispersal
of
drugs
as
well
as
payment
and
other
matters
related
to
drugs
completely
go
ahead.
I'll,
let
you
finish
but
kindly
remember.
The
reason
we
are
here
is
one
the
underpayment
to
the
pharmacies
and
steering
of
patients.
Those
are
the
two
biggies
that
that
is
the
reason
that
we're
here.
M
Go
ahead
I'll,
take
that
first
one.
If
we
go
back
to
the
public
chapter,
because
there
seems
to
be
a
lot
of
confusion
on
what
the
law
said
and
how
it
has
been
enforced.
M
I
won't
argue
that
that
section
three
b
excuse
me
section,
3
c
1
not
withstanding
a
lot
of
the
contrary
and
except
is
otherwise
provided
in
this
subsection,
see
a
pbm
shall
not
reimburse
a
contracted
pharmacy
for
a
prescription,
drug
or
device
an
amount,
that's
less
than
the
actual
cost.
For
the
pharmacy,
then
section
two
undersea
goes
into
a
number
of
exemptions
which
basically
send
one
that
is
important.
M
That
we
talked
about
is
the
appeals
process
right
that
is
3a
subdivision
c1
does
not
apply
to
a
covered
entity
or
pbm
that
establishes
a
clearly
defined
process
through
which
a
pharmacy
may
contest
the
actual
reimbursement.
That's
an
important
term
because
it's
defined
in
the
code
received
for
a
particular
drug
or
medical
product
or
device
right.
So
it
says
you
got
to
pay
him
at
cost
unless
you
have
an
appeals
process,
but
it
doesn't
say:
if
you
have
an
appeals
process,
it
doesn't
say
they
can
appeal
their
actual
costs.
M
It
says
they
can
appeal
their
actual
reimbursement.
Now
actual
reimbursement
is
defined
as
the
contracted
rate.
I
think
therein
lies
the
confusion
right,
so
it
says
you
got
to
pay
them
a
cost.
Unless
you
don't-
and
I
think
that's
what
the
department
tried
to
clear
up
in
their
last
bulletin,
but
I
don't
want
to
speak
for
them
too
much,
but
but
as
you're
talking
about
cleaning
things
up
that
that's
part
of
the
problem,
I
think,
with
with
this
section
of
the
code,
but.
A
G
Thank
you,
chairman
kumar,
and
thank
you
all.
We
all
want
less
expensive
medications,
that's
what
we
want,
and
I
understand
that
the
the
market
is
responding
to
different
levers,
to
try
to
change
those
pricing
mechanisms,
but
but
the
the
thing
that's
rather
confusing
to
all
of
us
is
you
know:
we've
passed
series
of
bills,
they're
in
the
green
books.
G
It's
called
law
they're,
the
chair,
the
assistant,
deputy
or
just
assistant,
commissioner,
just
testified
that
pbms
are
licensed
by
the
state
of
tennessee
and
specifically
that
department
and
and
we've
passed
law
last
year.
That
was
pretty
pretty
compelling
significant
reform,
and
yet
I
hold
in
my
hand
something
from
a
pbm,
and
it
says
that
effective
415
2022
that
there
will
be
this
is
the
policy
when
reported
correctly,
providers
should
receive
the
appropriate
reimbursement
reduction
of
average
selling
price
minus
22.5
percent.
G
So
that
doesn't
sound
like
that
anyone's
obeying
the
law,
which
says
that
that
someone's
going
to
be
reimbursed
for
22
percent
22.5
less
than
the
price,
and
so
we're
we're
we're
very
frustrated,
and,
I
would
say
pretty
much:
mad
is
I'm
hearing
from
the
department,
they
defend
the
plans
and
we're
just
trying
to
defend
patients,
and
so
that's
an
argument
that
I'm
willing
to
to
fight
every
day
of
the
week,
but
this
gets
for
it
gets
frustrating.
So
I'd
like
to
hear
from
you
all,
how
do
pbms
view
yourselves?
G
Are
you
part
of
an
insurance
company?
Are
you
part?
Are
you
separate?
Are
you
a
completely
separate
entity
and,
if
you're
a
separate
entity,
how
is
it
that
you
fall
under
erisa,
because
it's
a
risk
of
plans
that
govern
insurance
and
investment
products
and
you
all
are
vendors
supplying
a
a
service?
Thank
you,
mr
chairman,
for
your
indulgence.
B
G
B
M
Moore,
that's
an
excellent
question.
I'll
refer
to
to
michael
here
to
follow
up
on
anything
I
miss,
I
think
you
know
you
cited
a
a
letter
that
referred
to
asp,
minus
22,
there's
a
lot
of
acronyms
and
there
are
a
lot
of
acronyms
around
pricing.
So
I
think
it
would
be
a
question
of
whether
the
pharmacy
actual
cost
was
equal
to
asp,
or
maybe
they
paid
less
than
that,
maybe
their
actual
cost
was
was
closer
to
asp
minus
22
percent.
I
I
don't
know
you've
got
wholesale
acquisition
costs.
You've
got.
M
You
know
another
a
number
of
other
benchmark
pricing
models
in
in
in
the
system,
but
as
far
as
how
pbms
view
themselves
yeah,
I
think
that's
true.
I
tried
to
get
at
your
question
about
the
bubble
right.
M
It's
that
pbms
view
themselves
as
a
as
a
third
party
administrator
on
behalf
of
their
customers
right,
so
customers
can
be
insurance
companies,
but
they're
often
not
they're,
often
just
employers
that
are
trying
their
best
to
provide
coverage
for
the
employees,
because
that
is
a
you
know,
and
they
have
an
interest
in
their
employees,
well,
well-being
and
we're
charged
with
administering
those.
The
plans
on
their
behalf-
and
you
know
it's
not
uncommon.
M
I
think,
although
some
pbms
do
have
alignment
with
insurance
companies,
it's
not
uncommon
at
all,
and
it
actually
is
very
common
for
an
employer
to
bid
out
the
medical
and
the
pharmacy
separate.
So
it's
it's
pretty
common
for
an
employer
to
use
a
health
insurer
that
and
a
pharmacy
benefit
manager
that
have
no
ownership
and
that
actually
might
be
in
competition
with
each
other.
So
that's
that's
pretty
common!
So
use
an
example.
M
Acme
you
know
out
in
murfreesboro,
I'm
making
that
up
right
has
5000
employees
they're
going
to
get
bids
separately
on
their
medical
and
coverage
on
their
medical
policy,
so
they're
going
to
get
bids
from
blue
cross
cigna,
united
humana
others
on
the
medical
and
then
they're
going
to
get
a
separate
bid
on
their
pharmacy
and
it's
not
uncommon
for
them
to
use
a
pharmacy
benefit
manager.
That
has
no
relationship
and,
as
I
said,
would
be
in
competition
with
the
pbm
aligned
with
their
medical
benefit,
but
so.
N
Okay,
mr
chairman,
I'm
happy
to
I
mean
my
name
is
michael
powers.
Sorry
I
didn't
introduce
myself
earlier.
I
did
have
a
presentation,
but
we've
sort
of
jumped
right
into
it.
You
know
pbms,
do
we
we
are,
as
trey
pointed
out.
We
are
part
of
the
system
right
you
know,
and
and
what
that
looks
like
is
different
for
every
every
planned
sponsor
everyone
who
pays
for
their
insurance.
It
looks
a
little
different
there's,
not
one
contract
that
fits
everybody.
N
There
are
66
full
servers,
I'm
sorry,
there's
66
pvms
that
operate
in
the
marketplace
in
this
country
and
there
are
a
number
that
provide
one
little
service
or
several
that
provide
many
services,
and
so
there
are
instances
when
planned
sponsors.
As
trey
pointed
out
they
they
may
work
through
their
health
plan
and
they
may
have
two
or
three
pbms
providing
different
services
to
their
plan
to
their
to
their
beneficiaries.
That's.
A
Taking
us
beyond
where
we
are
again
we're
talking
about
underpayment
to
to
to
a
a
retailer
you're
paying
less
than
what
it
costs
them,
and
I
don't,
I
think.
Certainly
you
would
agree
that
nobody
can
be
in
business
under
that
circumstance.
You
will
agree
that
it
is
certainly
unfair
and
I
think,
taking
law
advantage
of
various
maneuvers
in
legislation
and
so
on.
It's
it's
pretty
well
sneaky
is
all
I
can
say
so
we
we
will.
We
will
allow
our
deputy
speaker
johnson,
to
put
us
straight.
D
Thank
you,
mr
chairman,
thank
you
so
much.
Thank
you,
mr
moore
and
mr
powers
for
being
here
when
we
passed
the
law
last
year
after
hearing
from
the
pharmacist,
they
indicated
they
see.
No
change,
have
the
pbms
complied
with
the
law
that
we
passed
yes
or
no.
M
I
mean
I,
I
can't
speak
for
every
pbm,
but
could
we
rep,
you
know
we're
with
the
trade
association,
but
under
you
know,
I
I'm
not
aware
of
any
intentional
sort
of
effort
to
not
comply
with
the
law.
I
think
there
might
be
some
disagreement
over
one
what
the
law
says
and
how
and
what
it
means
there
might
be
between
us
and
the
pharmacist.
M
There
might
be
some
disagreement
over,
even
if
or
even
if
we
agree
on
what
the
law
says,
how
that
is
applicable
to
a
self-funded
erisa
plan,
as,
as
chairman
powers
pointed
out,
might
be
preempted
by
state
law.
So
there's
a
lot
of
questions
about
the
bill
and
its
application,
but
that
would
be
I
I
guess.
M
D
M
Yes-
and
we
would
typically
pbm,
I
would
say-
would
come
in
at
the
pharmacy
counter
right,
so
the
patient
is
at
the
pharmacy
trying
to
get
a
drug
filled
for
a
prescription.
The
the
pharmacy
would
key
in
the
prescript
look
at
their
health
plan.
D
M
It
it
could
that's
just
not
how
the
supply
chain
works,
but
in
some
cases
it
does
so
that's
not
that's
it
never
does
so.
Sometimes
a
manufacturer
will
bypass
a
distributor
and
go
straight
to
handle
their
own
distribution,
but
when
you're
talking
about
generics,
which
are
the
vast
majority
of
drugs
filled
at
retail
pharmacy,
over
90
percent
you're,
typically
dealing
with
a
distributor
distributor
in
the
middle.
D
M
I
don't
know
if
we
have
a
slide
in
this
deck,
but
there
is,
there
is
sort
of
a.
There
is
a
slide.
I
can
get
you
that
shows
sort
of
sort
of
the
well.
We
might
have
the
profit
that
shows
profit
margins
of
any
everybody
in
between.
D
A
Members,
thank
you
for
your
patience.
We
still
have
to
talk
about
the
patient
steering
piece
and
keep
that
in
mind.
Chairman
powers,
you're
recognized.
C
Thank
you,
mr
chairman.
Just
going
back
to
the
the
psao
that
you
talked
about
a
little
bit
earlier,
does
it
do
the
independent
pharmacies
usually
contract
with
them,
or
do
they
contract
directly
with
the
ppe,
pbms
or
or
that
in
either
or
type
thing.
M
In
the
vast
majority
of
cases
they're
using
a
psa,
I
think
that,
and
most
of
the
terms,
I
think
part
of
the
problem
is
that
those
contracts
can
be
really
cumbersome
and
complex,
and
often
the
pharmacist
doesn't
know
if
it's
a
condition
of
their
psa
contract
or
if
it's
a
condition
of
their
pbm
contract,
which
the
pseo
negotiated
on
their
behalf.
So
I
think
you
know
it
would
be
helpful
for
policy
makers
to
be
able
to
to
look
to
get
some
transparency
around
psaos
because
they
control
a
huge.
M
They
control
the
other
side
of
the
of
the
supply
chain.
Right
and
one
side,
you
have
reimbursement,
which
is
the
health
plans
pbms,
but
on
the
other
hand,
on
the
other
side,
you
have
what
what
the
pharmacists
are
having
to
pay
for
the
drugs
and
all
the
hoops
they're
having
to
jump
through
in
order
to
get
those
at
wholesale.
M
A
Well,
the
last
piece
of
it
being
patient.
Steering
my
local
pharmacist
feels
that
they
are
the
patients
come
to
them
in
the
community.
They
belong,
they
know
each
other
and
there
is
a
relationship
there.
A
patient
comes
to
fill
in
a
prescription
that
is
filled
and
the
next
thing
you
know
they
get
a
notice
from
the
pbm
asking
them
to
go
to
a
particular
pharmacy
switch
to
mail
order,
or
their
medications
held
up
for
so
long
that
it
can
be
critical
that
their
treatment
is
delayed.
A
So
those
are
the
complaints
that
we
hear
and
kindly
it's
not
a
fair
system
that
takes
care
of
the
patients
as
well
as
takes
care
of
the
pharmacies
that
are
trying.
You
know
small
businesses
trying
to
make
a
living.
So
where
do
you
stand
on
this?
And
what
is
your
perspective
on?
It?.
A
N
Take
this
one
here,
so
you
know
again,
I
think
it
falls
back
to
the
fundamental
question
on
the
self-insured
marketplace.
I
mean
are
some
of
these
claims
coming
in
under
the
self-insured
marketplace
that
you
know
they
would
argue
that
this
they
have
still
federal
arrests
of
preemption
arkansas
act
900
dealt
with
a
law.
Oh
sorry,
the
rutledgers
pcma
decision
dealt
with
arkansas
act,
900,
which
was
about
how
pharmacies
are
reimbursed
using
a
different
pricing
methodology.
N
That
law
did
nothing
related
to
plan
design,
and
so,
if
a
plan
sponsor
a
payer
wants
to
use
to
drive
efficiencies
through
using
a
certain
network
of
pharmacies,
whether
it's
a
b
or
c
or
a
a
mix-up
of
those
or
if
they
want
to
use
mail
to
deliver
maintenance
drugs,
that's
something
that
they
choose
in
the
plan.
Design
process
and
some
of
those
payers
are
still
under
the
mindset.
They
still
have.
You
know,
preemption
under
the
federal
statute
dealing
with
erisa.
A
Well,
thank
you
in
a
way.
Yes,
I
see
the
point
that
it's
driving
efficiencies
and
pricing
in
the
market,
but
to
a
pharmacist
who
brought
you
the
patient
for
them
to
be
referred
away
from
them,
that's
painful
for
their
business
and
certainly
it's
no
different
than
a
big
box,
big
store
coming
into
a
community
and
basically
making
it
difficult
for
the
small
businessman,
mom
and
pop
operations
to
survive.
M
This
is
data
from
the
national
council
of
prescription,
drug
programs,
which
is
cited
in
peer-reviewed
journals,
but
actually
what
we're
seeing
in
the
tennessee
market
is
chain
pharmacies
going
down
independent
or
community
pharmacies
going
up
and
their
market
share
of
the
pharmacy
market
increasing
and
happy
to
provide
that
source,
but
it's
from
the
nc
pdp
as
far
as
their
as
far
as
pbms
and
health
plans,
low
reimbursements,
really
crushing
independent
pharmacy,
their
own
data.
This
is
from
the
national
national
community
pharmacy
association,
which
is
the
independence
washington
lobby.
M
M
So
we're
just
not
seeing
you
know,
reimbursement
policies,
you
know
driving
lower
margins
actually
on
the
prescription
drug
side.
So
I
would
push
back
a
little
a
little
bit
there.
A
Thank
you.
I
see
your
perspective
on
large
percentages,
but
to
an
individual
small
business.
It
can
be
a
significant
hit.
Chairman
speak
you're,
recognized.
H
I
went
back
and
looked
at
the
fiscal
note
from
the
previous
law
that
we
passed
and
there
was
no
request
of
any
personnel
from
the
department
of
commerce
and
insurance
for
additional
personnel
in
the
bill,
which
I'm
pretty
sure
fiscal
review
would
have
asked
them
if
they
need
any
additional
help.
So
maybe
that's
something
that
we
need
to
bring
fiscal
review
down
here
and
find
out
if
they
asked
the
department,
if
they
needed
help
in
this
bill
to
make
sure
they
could
implement
it.
But
getting
back
on
this
whole
thing
about
steering.
H
It
says
in
the
law
that
a
pbm
may
not
require
a
person
covered
under
a
pharmacy
benefit
contract
that
provides
coverage
for
prescription
drugs,
including
specialty
drugs,
to
pay
an
additional
fee,
higher
copay,
higher
coinsurance,
second
co-pay,
second
coinsurance
or
other
penalty
when
obtaining
prescription
drugs,
including
specialty
drugs
from
a
contracted
contracted
pharmacy.
The
law
also
clarifies
that
a
pbm
may
not
interfere
with
the
patient's
right
to
choose
a
contracted
pharmacy,
including
offering
financial
or
other
incentives.
H
H
M
H
Advocating
for
the
patient
is
our
job
being
fair
to
all
all
people
about,
because,
as
a
member
of
the
education
committee,
education
and
health
care
are
big
business,
big,
big
business,
and
so
when
you
see
these,
these
flow
charts
and
I'm
assuming-
and
I
could
be
wrong
here.
So
you
can
correct
me:
I'm
assuming
the
biggest
three
pbms
in
the
state
of
tennessee
aren't
independent,
I'm
assuming
they
are
part
of
a
normal,
a
bigger
corporation.
Would
that
be
a
correct
statement,
so
we
need
to.
H
We
need
to
continue
to
press
this
issue
moving
forward
and
making
sure
that
a
the
laws
that
we
pass
are
followed
with
the
spirit
of
the
law
which
they're
written
and
if
the
department
of
commerce
and
insurance
needs
help
in
implementation
and
enforcement.
I
am
sure
that
this
body
will
come
up
with
the
help
necessary
to
make
that
happen.
So
thank
you,
mr
chairman.
M
A
Rest,
we
will
go
back
into
session
and
I
think
we
all
understand
it's
a
complex
matter
with
many
confusing
pieces,
but
I'm
sure
that
all
of
us
will
ultimately
work
together
and
bring
up
better
legislation
that
will
serve
our
patients,
our
communities
and
the
small
businessmen
that
are
the
pharmacies.
Thank
you
for
your
patience.
Seeing
over
the
business
we
standard
journey.