From:  Harry L Gewanter, MD, FAAP, MACR

Re:  Opposition to proposed Amendment of 18 VAC 110-20-275

As a pediatrician and pediatric rheumatologist I am writing in opposition to the Board’s proposed amendments to 18 VAC 110-20-275.  Beyond a lack of understanding for the concept of amending this regulation, I have serious and significant concerns regarding the proposed amendment’s implications.

This change has the potential to seriously impair access to services for Virginians through the deference provided to chain pharmacies as compared to independent ones. The ability of an insurer/pharmacy benefit manager/specialty pharmacy to limit access to its clients/patients to its own pharmacies may be in the corporation’s best interest, but it is not in the patient’s best interest. As has been seen in other states, this type of forced choice through other means such as spread pricing has led to the financial failure and closure of these small businesses, especially in rural and inner city areas. 

The lack of transparency that results from “increasing the amount of white on the label” is another concern. The patient will assume that the pharmacy where the prescription is obtained is the pharmacy that filled the prescription, thereby placing an inappropriate burden upon that pharmacy should the patient have any questions or issues. Further, I could easily conceive of a potential liability issue for that pharmacy and pharmacist since they are now part of the distribution chain but cannot vouch for the prescription or its handling during shipment, etc.

As a physician who has infused specialty medications for my patients, I am especially concerned about Part C of the proposed amendment.

C. Delivery to a practitioner of the healing arts licensed by the board to practice pharmacy or to sell controlled substances or other authorized person or entity holding a controlled substances registration authorized for this purpose.

This amendment would allow an insurer/pharmacy benefit manager/specialty pharmacy to minimize my ability to provide my patients with the medications we have agreed are in their best interest. Similar to the distributing pharmacist, this  places an undue burden and liability upon me to confirm and ensure the medication is as ordered, has been shipped and handled correctly, etc., with an inability to confirm these details. This “white bagging” system adds another layer of cost and complexity to an already overly complex and costly drug delivery system without adding any benefit to the patient, the ultimate payer.

While there are numerous other reasons to oppose this unnecessary amendment, I think these make the point that this proposal should be roundly defeated. It seems to only benefit the insurer/pharmacy benefit manager/specialty pharmacy component of the drug supply chain, but not the patient, pharmacist or any of the health care providers involved in the actual care of the patient.

Thank you for your consideration.

Harry L. Gewanter, MD, FAAP, MACR

Richmond, VA