The Problem

the problem

What Happens at the Pharmacy Counter?

Patients across Virginia are fighting every day to stay healthy and have access to affordable medication. Many patients arrive at the pharmacy counter to pick up their prescriptions only to be faced with high out-of-pocket costs that many may not be able to afford. Out-of-pocket costs are any expenses paid for a prescription that aren’t covered by insurance plans. For many, especially those with chronic conditions, innovative medical treatments can make all the difference in their ability to lead healthy, productive lives. And yet, high out-of-pocket cost burdens associated with their essential treatments are keeping them from being able to access their medications.

Patients in Virginia deserve to have policies in place that make the well-being of the patient top priority.

Why Does This Happen?

Thanks to new innovative treatments, many diseases that were once fatal are now being treated as manageable chronic conditions and, for other diseases, new treatments have greatly increased average life expectancy. However, under many health insurance plans, patients living with chronic conditions are required to pay thousands of dollars in out-of-pocket costs to access the treatments their health care providers have prescribed. This is true for medications used to treat cancer, HIV/AIDS, arthritis, multiple sclerosis and other debilitating and life-threatening diseases. When high out-of-pocket costs become a barrier to access, patients find themselves facing difficult decisions about whether to take medically necessary treatments or to risk their family’s financial stability.

What Should Happen at the Pharmacy Counter?

When Virginians pick up their medications from the pharmacy, they shouldn’t be confronted with high out-of-pocket costs, leaving them to choose between their health and financial stability. Virginia patients, especially those living with chronic illnesses, deserve affordable access to the medications and drugs they rely on to live healthy and productive lives.

The Solution

Virginians should not have to delay or forgo treatment simply because of high out-of-pocket costs. The Virginia General Assembly must increase protections to ensure patients have access to high quality, affordable care. Virginia legislators support legislation that limits the out-of-pocket costs Virginians are required to pay for each prescription. The Virginia General Assembly already passed an out-of-pocket cost cap for insulin in 2019, and should now focus on expanding out-of-pocket cost caps to limit how much Virginia patients are paying from their own wallets.

  • Capping Out-Of-Pocket Costs – Out-of-pocket cost caps limit the amount that an individual has to personally contribute to pay for covered prescription drugs and healthcare services. Virginia passed an out-of-pocket cost cap for insulin in 2019 and could expand out-of-pocket cost caps to cover more prescriptions.
  • Reforming Benefit Designs – Benefit designs are rules that structure health insurance plans and can determine how an individual can access healthcare services. State policy action can change how specific insurance practices – like utilization management, high cost-sharing requirements, and other barriers – limit patient access to care.
  • Creating Rebate Pass Throughs – Negotiations between biopharmaceutical companies and private healthcare plans result in significant rebates, however these savings are not passed through to patients at the pharmacy counter. There has been a growing movement to mandate that any negotiated rebates are passed along to patients.
  • Reforming pharmacy benefit managers (PBMs) – PBMs are often unseen middlemen in the pharmacy supply chain that lead to higher out-of-pocket costs for patients. States like Georgia, North Carolina, and Florida have started passing laws to require greater transparency into how PBMs operate to ensure that patients benefit from any potential savings.