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. For many patients, especially those with chronic disorders, innovative medical treatments can make all the difference in their ability to lead healthy, productive lives. And yet, a multitude of barriers are keeping essential treatments out of reach because the patient cannot afford the high out-of-pocket costs. Patients are also kept in the dark about why their prescriptions cost so much at the counter.

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

Why Does This Happen?

Virginians are affected by many complex policies involving insurers and middlemen like pharmacy benefit managers (PBMs), which have impacted the cost of prescription drugs. Rising out-of-pocket costs, complicated benefit designs, and unclear pricing policies mean that patients often have to make hard decisions at the pharmacy counter, impacting their health and quality of life. 

What Should Happen at the Pharmacy Counter?

When Virginians pick up their medications from the pharmacy, they should be able to easily understand the factors that go into the price they pay – like what rebates are negotiated and how these savings affect cost. There should be greater transparency surrounding the layers of middlemen like PBM’s and insurers who profit while patients pay higher and higher costs. Greater transparency will lead to lower out-of-pocket costs and relief at the pharmacy counter.

The Solution

Virginians need solutions that actually impact what they pay at the pharmacy counter, such as commonsense plans to cap out-of-pocket costs for patients on the medications they need. The Virginia General Assembly could take action on the below issues to help patients afford lifesaving treatments at the pharmacy counter: 

  • 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.
  • 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.
  • 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.