HB 58-CONTRACEPTIVES COVERAGE:INSURE;MED ASSIST  3:56:15 PM CO-CHAIR SNYDER announced that the final order of business would be HOUSE BILL NO. 58, "An Act relating to insurance coverage for contraceptives and related services; relating to medical assistance coverage for contraceptives and related services; and providing for an effective date." 3:57:05 PM REPRESENTATIVE MATT CLAMAN, Alaska State Legislature, introduced HB 58, as prime sponsor. He shared that, since the 1990s, 28 states have required health insurance plans regulated by the state that provide coverage of prescription drugs and devices to also cover prescription contraceptives. Under the Affordable Care Act (ACA) of 2010, these policies were extended in several ways, he continued, and the contraception coverage guarantee in the ACA stems from Section 27.13 of the Public Health Service Act (PHSA). He stated that the PHSA requires non-grandfathered health insurance coverage and employer sponsored group health plans to cover preventative services without cost sharing. He added that section 27.13 of PHSA requires coverage of women's preventative services as defined by the Health Resources and Services Administration (HRSA). He continued that HRSA asked the institute of medicine to recommend the women's preventative services that should be covered, and based on this recommendation, HRSA defined women's preventative services to include all contraceptives approved by the Food and Drug Administration (FDA). He said that sterilization procedures and patient education and counseling of women of reproductive capacity is prescribed by a health care provider, which is collectively referred to as contraceptive services. REPRESENTATIVE CLAMAN explained that the final preventative services rules issued required insurers and group health plans to cover all such contraceptive services. Recognizing that some religions object to contraceptive coverage, he added, the federal government issued rules that excluded religious employers from the contraceptive coverage guarantee. More recently, some states have amended and expanded its requirements to match the federal guarantee. He shared that some of these state provisions go beyond the federal guarantee, ensuring that women may receive an extended supply of a contraception method at one time, usually being a twelve-month supply rather than a typical one- to- three-month supply. REPRESENTATIVE CLAMAN shared that HB 58 would put into Alaska statutes language that is consistent with the standard that is set in the federal contraceptive care guarantee. He added that it also would add language that would mandate coverage for dispensing up to twelve months of prescription contraceptives at a time. 3:59:20 PM REPRESENTATIVE CLAMAN paraphrased paragraph one of the Sponsor Statement [hard copies included in community packets], which read as follows [original punctuation provided]: Alaskan women often face numerous challenges when trying to access reproductive health care and prescription contraceptives. Women living in rural Alaska have less access to healthcare services and therefore less reliable access to prescriptive contraceptives. Fisherwomen working on a boat for months at a time need longer supplies of prescription contraceptives. For women who are trying to balance their personal health with busy work and family schedules, making multiple trips to the clinic or pharmacy is a significant barrier to accessing consistent contraception. REPRESENTATIVE CLAMAN stated that research featured in the journal of Obstetrics and Gynecology [hard copies included in committee packets] shows that women who are dispensed a twelve- month supply of contraceptives have a 30 percent drop in unplanned pregnancies, and a 46 percent drop in the likelihood of abortion in women dispensed a one-to-three-month supply. He added that HB 58 would also save money for the state. He noted that his office sponsored a prior version of this legislation in a previous legislature, the Department of Health and Social Services (DHSS) fiscal note estimated a $1.35 million dollar savings annually due to the reduction in unplanned pregnancies. He commented that the women in his family support HB 58. He shared his understanding that the women in his family support it because it is not only often time-consuming and inconvenient to obtain contraception every one to three months, but also because improved access to contraceptives also means improved health for women and families. REPRESENTATIVE CLAMAN added that HB 58 would also help protect victims of domestic violence. He said that there has been an increased awareness of domestic violence and sexual assault in both Alaska and on the national level. He relayed that movements such as "Me Too" and "Time's Up" have shown that more support needs to be given to those that have experienced and are currently experiencing that type of violence. He noted the issue of contraceptive coercion, where abusers dictate when and how contraceptives can be accessed as a means of gaining power and control over victims. He relayed that research from a 2011 National Intimate Partner and Sexual Violence Survey shows that around 9 percent of U.S. women report having an intimate partner who tried to get the woman pregnant or refused to use a condom. He opined that, by providing consumers a twelve-month supply of birth control, HB 58 would critically support victims and survivors by assisting those who are attempting to live as safely as possible in the short term while working toward longer-term safety. He shared that, supported by a long- standing body of evidence, contraceptives services have long been recognized by both government bodies and private-sector experts as a vital and effective component of preventative and public health care. He shared his understanding that contraceptive use helps women avoid unintended pregnancy and improve birth spacing, which have substantial consequences for infants, women, families, and society. He added that cost can be a barrier to contraception for individual women, but that the evidence suggests that insurance coverage of contraceptive services and supply without cost sharing is a low-cost and even cost savings way to help women overcome the obstacle of personal cost. 4:03:03 PM LIZZIE KUBITZ, Staff, Representative Matt Claman, Alaska State Legislature, provided the Sectional Analysis of HB 58 on behalf of Representative Matt Claman, prime sponsor. She paraphrased Section 1 through Section 5 of the Sectional Analysis [hard copies included in committee packets] which read as follows [original punctuation provided]: Section 1 AS 21.42.427. Coverage for contraceptives. Amends AS 21.42 by adding a new section which (1) requires a health care insurer to provide coverage for prescription contraceptives and medical services necessary for those products or devices; (2) requires reimbursement to a health care provider or dispensing entity for dispensing prescription contraceptives intended to last for a 12-month period for subsequent dispensing; (3) prevents an insurer from offsetting the costs of compliance; (4) prevents an insurer from restricting or delaying coverage for contraceptives; (5) if the provider recommends a particular service or FDA-approved item based on a determination of medical necessity, the plan or issuer must cover that service or item without cost sharing; and (6) exempts religious employers if certain criteria are met. Section 2 AS 29.10.200. Limitation of home rule powers. Amends AS 12.10.200 by adding a provision applying to home rule municipalities. Section 3 AS 29.20.420. Health insurance policies. Amends AS 29.20 by adding a new section clarifying that municipal health care insurance plans that are self-insured are subject to the requirements of sec. 1. Section 4 AS 39.30.090. Procurement of group insurance. Clarifies that a group health insurance policy covering employees of a participating governmental unit is subject to the requirements of sec. 1. Section 5 AS 39.30.091. Authorization for self- insurance and excess loss insurance. Clarifies that a self-insured group medical plan covering active state employees provided under this section is subject to the requirements of sec. 1. 4:06:26 PM MS. KUBITZ continued by paraphrasing Section 6 through Section 9 of the Sectional Analysis, which read as follows [original punctuation provided]: Section 6 AS 47.07.065. Payment for prescribed drugs. Requires the Department of Health and Social Services to pay for prescription contraceptives intended to last for a 12-month period for subsequent dispensing for eligible recipients of medical assistance, if prescribed to and requested by the recipient, as well as medical services necessary for those products or devices. Distributed by the Office of Representative Matt Claman 3.30.2021 2 Section 7 Uncodified law - applicability Requires the Department of Health and Social Services to immediately amend and submit for federal approval a state plan for medical assistance coverage consistent with sec. 6 of this Act. Section 8 Uncodified law - applicability Makes sec. 6 of the Act conditional on the approval required under sec. 7 of the Act. Section 9 If sec. 6 of this Act takes effect, it takes effect on the day after the date the revisor of statutes receives notice from the commissioner of health and social services under sec. 8 of this Act. MS. KUBITZ explained the changes that have been made since this legislation was originally introduced in 2017. She stated that during the Thirtieth Alaska State Legislature, multiple changes were made to the legislation. First, the House Health and Social Services committee adopted a committee substitute that made changes based on recommendations by the Department of Administration and the Department of Commerce, Community, and Economic Development. She shared that these changes would give health care administrators the ability to enact reasonable cost containment measures [as shown in Section 1 of the Sectional Analysis] as well as make certain that the bill would apply to active state employees [as reflected in Section 4 and Section 5 of the Sectional Analysis]. Second, she continued, the House Finance Committee adopted an amendment that clarified that municipalities that were self-insured were also captured under the bill, and must cover a twelve-month supply of contraceptives. Third, she continued, two amendments were adopted on the House floor: the first changed the effective date to update it, and the second amended created a narrower religious exemption to contraceptive coverage than is currently provided under federal law. MS. KUBITZ continued, explaining that during the Thirty-First Alaska State Legislature, one significant change was made to the legislation. In the re-drafting process, she said, the office of Representative Claman amended the legislation after receiving feedback about coverage for male sterilization; therefore, the federal guarantee does not require similar coverage for a vasectomy or male condoms, she said, but upon research, it was discovered that some states required coverage of male sterilization, therefore the bill was amended to add clarifying language so that high deductive plans can apply the policy deductible to adult male sterilization benefits so that enrollees in these plans can maintain health savings account eligibility. 4:10:18 PM CARMEN LOWRY, Executive Director, Alaska Network on Domestic Violence and Sexual Assault (ANDVSA), testified in support of HB 58. She shared that (ANDVSA) is a membership-based organization that is governed by 23 community-based agencies providing services to victims of domestic and sexual violence. She explained that ANDVSA offers its enthusiastic and unqualified support for HB 58, which is a bill that requires insurance coverage of all FDA-approved contraceptive methods and requires insurance plans to cover a one-year supply of birth control at a time. She stated that ANDVSA supports the bill because increased access to the full range of contraceptive methods results in increased safety and well-being for all women in Alaska. She noted that it is especially important in those rural areas where supply chains, transportation options, and access to telehealth via Internet are vulnerable, which she expressed has been evident during the COVID-19 pandemic. MS. LOWRY continued by sharing some reasons as to why increased access to birth control is so important for those women who may be experiencing domestic violence. First, a common and early controlling behavior used by an abuser is to isolate the victim from others in her network of support, she explained. This means, then, that this specific victim-survivor will be unable to connect with friends or family, unable to ask others to assist with transportation or childcare and have restricted freedom of movement that is required to gain access to birth control methods. She expressed that the ability to have a twelve-month supply means that, for a woman who experiences this type of commonly exercised abusive behavior, the woman would know that at least she still has the ability to have control over whether she becomes pregnant or not. MS. LOWRY added that another abusive strategy often used is known as "Reproductive and Sexual Coercion." This refers to these types of behaviors: explicit attempts to impregnate a partner against her will by controlling her access to contraceptives; controlling outcomes of a pregnancy by limiting her abilities to access pre- and/or postnatal care; forcing a partner to have unprotected sex; and interfering with contraceptive methods, including tampering with her contraceptive methods. She explained that isolation, restricted freedom of movement, limited access to contraceptives, and limited control over how and when to use those contraceptives are examples of what it is like for some women who experience domestic violence. She expressed that these women are denied the right to make intentional choices about pregnancy. MS. LOWRY shared that there are still more harmful impacts that may occur as a result of a forced or coerced pregnancy. For example, homicide is a leading cause of pregnancy-associated mortality in the United States. She shared her understanding that multiple studies show that domestic violence increases as pregnancy progresses and in post-partum, and that research conducted across multiple sites has found that women with unintended pregnancies were four times more likely to experience domestic violence than women whose pregnancies were intended. She added that HB 58 would increase access to birth control for all women and, specifically for women who experience domestic violence, would reduce the likelihood that they will experience new or continued violence as a result of an unintended pregnancy. She said that HB 58 would ensure that every woman across Alaska is able make intentional choices about her reproductive health, and overall well-being, and it would ensure access to a 12-month supply to contraceptives. 4:15:00 PM REPRESENTATIVE FIELDS asked Ms. Kubitz how many states go further than the language in HB 58 and require coverage for contraception that may not need a prescription to obtain. MS. KUBITZ responded by referring to a paper by the Guttmacher Institute, entitled, "Insurance Cost of Contraceptives" [hard copies included in the committee packet], which details topics such as the federal guarantee and the actions taken by states to expand upon the guarantee. She noted that there is a table in the back of the paper that discusses the various ways states have gone beyond the federal guarantee and have required coverage for over-the-counter contraception without a prescription. She shared her understanding that the table that shows that twelve states and the District of Columbia require coverage of methods received over the counter. REPRESENTATIVE FIELDS asked Ms. Kubitz to explain the rationale for the modest scope of proposed legislation rather than going further, as the other twelve states have. MS. KUBITZ answered that the bill was based off of the federal guarantee, and shared that her understanding was that per the Affordable Care Act, over-the-counter medicine and drugs were removed from the list of reimbursable medical items if purchased without a description. She said that there may be opportunity to go further and expand. She added that there are some states that allow pharmacists to do the prescribing right on site for some contraceptives. REPRESENTATIVE FIELDS asked what the benefit would be for allowing broader authority for pharmacists. MS. KUBITZ replied that she would like to defer the question to Dr. Tina Tomsen. She said that her understanding is that women in Alaska currently have two options: women can call their doctor and get a prescription for an over-the-counter method such as emergency contraception, or women can go to the pharmacy and purchase it themselves without coverage. 4:18:24 PM TINA TOMSEN, MD, answered Representative Fields' question, and shared that the only contraception over the counter in Alaska is the "morning after" pill, also known as Plan B. All other require a prescription, she said, and currently there is no authority in the state for pharmacists to prescribe the prescription. She relayed that there may be some states that allow pharmacists to prescribe on site, but she is not familiar with those numbers. She shared that Plan B has been determined safe enough to be available over the counter, but there is a better pill that is more effective over a longer period of time called "Ella," or ulipristal acetate, that requires a prescription. She noted that if a woman of any age needs a morning after pill, she could pay a price of "about $50" to buy the Plan B pill over the counter without a prescription or insurance coverage, or she could get a prescription from a physician for the improved Ella pill and have that covered by insurance. 4:20:51 PM LORI WING-HEIER, Director, Division of Insurance, Department of Commerce, Community & Economic Development (DCCED), responded to Representative Fields' question. She said that she is sure that there are ways that contraceptive care could be expanded upon, and opportunities to broaden the services the pharmacists are able to perform in respect to contraception. 4:22:08 PM REPRESENTATIVE KURKA asked Ms. Wing-Heier what the process would look like for an institution to obtain a religious exception [from providing contraceptive coverage]. MS. WING-HEIER replied that, if an insurer were to apply for a religious exception, it would be written in to the insurer's plan documents as such. The plan would specifically say that that law [requiring contraceptive coverage] doesn't apply because the state allowed the exclusion due to religious concerns. REPRESENTATIVE KURKA asked whether the plans would be dependent on the business' [decision to enact a religious exemption], or be the default for all plans. MS. WING-HEIR responded that it would not be the default for all plans. She explained that a business would have to present with its insurer that it is a religious organization, such as the Catholic Church, does not believe in birth control. REPRESENTATIVE KURKA noted that there was a lot of discussion with "Obamacare" regarding privately held businesses that had strong religious beliefs such as Hobby Lobby, and shared his understanding that this bill would not protect these sorts of businesses. MS. WING-HEIER responded that she would have to research that, and shared that she is not aware of that being an issue in Alaska. She said that she has worked with churches, but is not aware of a private employer, such as Hobby Lobby, that has requested that its plan not include birth control. REPRESENTATIVE KURKA asked for clarification on whether this exemption applies only to religious institutions and not businesses. MS. WING-HEIR responded that she would need to research this as well, but that she would say that it's [only applicable to] religious organizations. 4:25:27 PM CO-CHAIR SNYDER opened public testimony on HB 58. 4:25:51 PM MORGAN LIM, Alaska Government Affairs Manager, Planned Parenthood Alliance Advocate, testified in support of HB 58. He relayed that Planned Parenthood strongly supports HB 58 and that it would improve access to the full range of contraceptive methods by requiring insurance providers to cover a year's supply of birth control at one time. He said that it would also build upon the ACA's contraceptive coverage mandate to ensure that all people have meaningful and timely access to contraceptive care. He expressed that people in Alaska deserve affordable and accessible birth control, regardless of insurance care, income, or life circumstances. He shared his understanding that most birth control users are forced to refill contraceptive prescriptions every month, which is a burden for many, especially during the COVID-19 pandemic, and it increases the odds of experiencing an unintended pregnancy. He said that even with ACA in place, insurance carriers are permitted to deny or delay aspects of certain contraceptive methods by applying medical management techniques such as prior authorization or step therapy. MR. LIM expressed that HB 58 would have a huge impact for patients in rural areas of the state and also for people who have limited access to transportation, as it can be burdensome for these individuals to travel to a pharmacy and get a prescription every month. He shared a statistic that one in four women say that they have missed pills because they could not get the next birth control pack in time. He opined that an extended supply of contraception is especially important for young people, survivors of intimate partner violence, people who work multiple jobs or have low income. He explained that these people are disproportionately indigenous, black, and people of color, due to a history of racism that permeates the system. He added that the pandemic has highlighted the need for extended supply with one in three women reporting difficulty accessing birth control as a consequence of COVID-19. He concluded that HB 58 would ensure that patients have a consistent and predictable supply of contraception. 4:28:38 PM SARAH KHLIFI, Community Advocate, Alaska Children's Trust (ACT), testified in support of HB 58. She shared that the ACT is a statewide, lead organization focused on the prevention of child abuse and neglect. She said that, when discussing the improvement of overall family wellbeing, pregnancy planning, spacing of pregnancies, and pregnancy prevention are often overlooked. There is more of a focus on the services for children and families after birth rather than thinking about the economic and social services in which people become pregnant. She said that family planning and access to contraception is essential for families to achieve economic security by preventing unwanted pregnancy, which can impede a family's ability to achieve upward trajectory of economic mobility. She shared that one of the biggest stressors to families is financial instability, and this sort of stress and tension in families can drive child abuse and neglect. She opined that if the families that are most at-risk of falling into poverty cannot access affordable birth control, the cycle of poverty and abuse will continue for these children and families. MS. KHLIFI shared her understanding that people are relatively less likely to be prepared for parenthood and develop positive parent-child relationships if a birth is unplanned or the parents are teenagers at the time of pregnancy. This also can lead to larger families, which can impede a parent's ability to impact each child. She expressed that all of these factors can influence children's mental and behavioral development and influence educational achievement. She concluded by noting that this legislation would make it possible to close accessibility gaps for individuals living off the road system and working seasonal jobs, or facing other barriers, by allowing access to a twelve-month supply of contraceptives at a time. She opined that HB 58 would supply necessary tools for all children and families to thrive, and would prevent child abuse and neglect by giving people more control over their individual birth control needs. 4:31:06 PM VALORRAINE DATTAN testified in support of HB 58. She said that when she went away to college out of state, her doctor recommended that she take multiple of the birth control which she took for medical reasons with her, but insurance wouldn't cover it. She was fortunate enough that her parents were able to purchase the birth control for her out of pocket, and for this reason she didn't have to worry about finding a doctor in a new state that she had never been to before, or getting around a new city without a car. She expressed that many other women are not as fortunate as she is, especially in rural Alaska, where it can be difficult to get to a pharmacy every month. If a woman is in an abusive home, she continued, it can be dangerous or outright impossible [to obtain birth control every month]. She expressed that it's necessary for women to be able to plan their lives and create healthy families and futures. She said that both individual families and communities would benefit from extended access to birth control, and would provide cost savings to the individual as well as insurance companies to prevent additional costs associated with unintended pregnancies and child welfare. 4:32:51 PM LYNETTE PHAM testified in support of HB 58. She said that she supports the bill because of the benefits it would provide to rural women, seasonal workers, students, and others. She expressed that accessible birth control can be life-changing in many ways. She shared her understanding that HB 58 would decrease the odds of women experiencing unintended pregnancy, reduce the need for abortion care, and improve the lives of Alaskans across the state. She added that during the pandemic, many people lost their jobs, and getting a twelve-month supply of birth control would've allowed for more security for these individuals, and for less painful symptoms for those who use birth control for medical reasons. She added that individuals who live in rural areas and cannot travel to pick up birth control, the bill would help these individuals overcome accessibility barriers. She urged the committee to pass the bill. 4:34:10 PM KAREN BAKER testified in support of HB 58. She said that she has been fortunate to have access to long-term birth control, but knows that that is not the case for everyone. She emphasized the importance of twelve-month birth control particularly for those who have seasonal employment, live off the road system, are teachers and have lapses of coverage in the summer, have been laid-off, or have unsafe home situations. She expressed that birth control is a safe and necessary medicine, and said that Alaskans deserve reliable access to these prescriptions. She said that "twenty-one states and Washington D.C." have laws that require twelve-month supplies of birth control, and she opined that Alaskans deserve to have the same level of care. 4:35:15PM RUSSELL DENNIS testified in support of HB 58. He shared his understanding that leading medical experts recommend access to a full range of contraceptives, and he opined that it's time for Alaska to join the other states [that allow for twelve-month supplies] and increase access to birth control. He expressed that the benefits include reduced abortion rates and savings to the state, to the insurance companies, and to Alaskan families. 4:36:05 PM SERENE OHARA JOLLEY testified in support of HB 58. She shared that when she first moved to Alaska, she lived outside of Cantwell, Alaska, and worked construction in the summer, where there were no standard days off in remote construction. While there, she said she started to experience symptoms that she could not explain, and was able to get a day off to drive to Fairbanks, Alaska, to see a doctor. She learned that she was experiencing Perimenopause. Ideally, she continued, she would be able to see a compound pharmacist about this issue, but that was not an option for her living in a rural area. Alternatively, she said that her doctor recommended going on oral birth control to replace the hormones her body was no longer making. She went to Fred Meyer to fill her prescription and, to her surprise, was only allowed a one-month supply. She said that her prescription was for one year, and tried to explain to the pharmacist that she lived hundreds of miles away and would not be able to take off work and return each month, but there was nothing the pharmacist could do. She explained that, after a month of being on the medication, it was clearly working, but she had no way to get back to Fairbanks to fulfill her prescription. She said that she had to confide in her boss as to why she needed a day off at the end of each month, and that no one should have to tell their boss their medical information, especially to obtain an already prescribed medication. Each month, she explained, she missed a day of work and spent hundreds of dollars in gas over the course of the summer in order to drive to get a prescription that was deemed safe and necessary. She shared her understanding that this is simply because insurance companies and politicians have denied her access. She noted that she was lucky as well because her boss was compassionate, and she was on the road system. Many others live off the road system, she said, or work on fishing ships, or are firefighters in remote locations, and cannot access a pharmacy. She urged the passage of HB 58. 4:38:19 PM DONOVAN CAMP testified in support of HB 58. He shared that, when he was in college in Fairbanks, he and his partner were cohabitating and had easy access to family planning during the semester. During the summer, however, he and his partner were working long hours and it became more inconvenient to get access to birth control, and they had a pregnancy scare. He shared that he and his partner were fortunate that it was only a scare, and they didn't have to significantly alter their lives, such as dropping out of college. He said this is an example of how just a slight inconvenience could have life-long impacts. He encouraged the passage of HB 58 to limit the barriers to accessing the tools that are necessary for family planning. 4:40:19 PM CHRISTINE ROBBINS testified in opposition to HB 58. She opined that it is unconscionable to force employers to pay for employee's contraceptives. She asserted that family planning is an individual's responsibility, and shared her understanding that [the state] does not need to encourage sexual immorality or the "murder of the unborn." She expressed her opinion that contraceptives would allow a rapist or an abuser to hide their behavior, and that abstinence is the solution. 4:41:49 PM CO-CHAIR SNYDER, after ascertaining that there was no one else who wished to testify, closed public testimony on HB 58. 4:42:10 PM The committee took a brief at-ease at 4:42 p.m. 4:42:32 PM REPRESENTATIVE MCCARTY asked Dr. Tomsen whether "forcing" a twelve-month allowance of birth control would compromise the physician's ability to verify the care of the patient. DR. TOMSEN answered that there is nothing in the proposed legislation that requires a twelve-month prescription. She explained that some patients may warrant a shorter prescription if, for example, a doctor was worried about the patient's blood pressure, but that the vast majority of prescriptions make sense to be for twelve months. She said that in her office, there was a policy that if a patient called in, the nurses could refill the prescription for a month or two if the patient had reached the twelve-month limit. This ensured that the patient would still have birth control until able to get in to the office. She noted that women who have a birth control pill prescription and are required by their insurance companies to come in every one to three months are at a disadvantage, and that HB 58 would overcome that disadvantage. REPRESENTATIVE MCCARTY shared his understanding that this bill is not related to mail-in prescriptions, and that it would not resolve the issue of people having to travel great distances to get prescriptions, but is instead a pharmacy management decision. He asked whether his understanding is correct. DR. TOMSEN responded that HB 58 would allow a patient to ask for as many packs of a prescription that the patient desires at a time, up to a twelve-month supply. She said that a "hiccup" between pharmacy benefit managers or insurance companies is a different issue outside of her knowledge base, but shared that she is in favor of a patient being able to get up to twelve months of a prescription at a time. MS. KUBITZ cited her knowledge of a legislative research paper that said that typically insurance carriers in Alaska will fund medication from retail pharmacies for 30 days or 90 days. According to this review, she relayed, which included correspondence with the Division of Insurance, pharmacists, and insurance representatives, these limits are not codified in regulation or statute, but are standard operating procedure for insurers. She said that it is the choice of the insurer to not cover twelve months at a time. Patients can have a [twelve month] prescription and know that it's possible to retrieve it every one to three months, but it's up to the insurer whether to cover the twelve-month supply at one time. 4:48:18 PM REPRESENTATIVE MCCARTY asked Dr. Tomsen what would happen if a patient were to lose medication included in a twelve-month prescription. DR. TOMSEN responded that a lost prescription is handled on a case-by-case basis and the patient's chart would be reviewed. She explained that a refill prescription may be called in, depending on the circumstances. She said it would be handled in a similar way as any lost prescription is handled. 4:50:16 PM REPRESENTATIVE PRAX shared his understanding that the driver for the one-month prescription limit is economic rather than medical. He asked if this is correct. MS. TOMSEN answered yes, the driver for requiring patients to fulfill prescriptions every month or three months is financial. She shared that when she had prescriptions when she was young, the limit did not exist, but it developed over time as a way for insurance companies to limit their outlay. REPRESENTATIVE PRAX asked for more specific details about the cost. MS. TOMSEN answered that, for a brand name birth control pill, a one-month prescription can cost from $60 to $80, or as little as $10. She said that it likely costs the drug company "about a dollar" to produce a month's supply of birth control. She said that there are also problems with generic brands, but this is why the bill would allow for generic substitutions for identical products. However, she said, there is an occasional patient that will have a dysphoric reaction to one generic pill, but has no negative reaction to the same brand name pill. REPRESENTATIVE PRAX shared his understanding that the cost would be around $600 or $700 per year, or $10 to $60 per month. He asked if this is correct. MS. TOMSEN responded yes, the price of contraception varies considerably, but may be as little as $10 per month. She shared that she doesn't know the kinds of deals the pharmacy, the pharmacy benefit managers, and insurance companies are making. She said that she is looking at it from the retail side, just as patients are, because more detailed information about the actual cost and price isn't available to her. 4:53:45 PM REPRESENTATIVE SPOHNHOLZ expressed her understanding that HB 58 is not about the patient and doctor relationship, which she said is a relationship that already exists, but instead about the insurance company and patient relationship. She opined that the issue is that the insurance company is not fulfilling a full twelve-month prescription that has already been provided for by the doctor. She asked Ms. Kubitz whether her understanding was correct. MS. KUBITZ responded yes, and that health care plans are currently not required to cover a twelve-month supply, and the insurance company can therefore determine whether a twelve-month supply will be covered. REPRESENTATIVE SPOHNHOLZ referred to Representative Prax's earlier question on whether the mandate was economic and not medical, and offered her understanding that the economic constraint was on the part of the insurance companies trying to limit the amount of birth control being covered in a given month and not necessarily anything else. She asked whether this is Ms. Kubitz' understanding as well. MS. KUBITZ responded that that is her understanding as well, and that her research has indicated that covering the twelve-month supply does not raise insurance premiums, but instead would be a cost-savings measure in the long run, particularly when it comes to costs associated with an unintended pregnancy. REPRESENTATIVE SPOHNHOLZ shared that there is research that shows that about 50 percent of all pregnancies, nationwide but also in Alaska specifically, are unintended. She opined that one of the most important things that can be done to help support families to reduce child abuse and neglect and also create more economic independence, as was heard earlier in the meeting from ACT, is to allow women the ability to choose whether to conceive. She noted that this likely saves money on things such as insurance co-pays, however reducing unintended pregnancy also saves money. She noted that it is very expensive to have babies, and not nearly as expensive to prevent a pregnancy that was unintended in the first place. 4:57:05 PM CO-CHAIR ZULKOSKY asked Ms. Kubitz whether she could speak to the fiscal note, and if there is a fiscal impact brought on by the legislation. MS. KUBITZ responded that there are three zero fiscal notes: one from the Division of Retirement and Benefits, within the Department of Administration; another from the Medicaid Services Division, within the Department of Health and Social Services (DHSS), and a third from an insurance operation overseen by the Department of Commerce, Community, and Economic Development. She said that previous iteration of this legislation involved a unique situation where there was an analysis done by DHSS' Medicaid Services Division that showed a cost savings, based on research done by the California Medicaid Program [hard copies included in committee packets], in which patients were given a twelve-month supply at one time. She relayed that the analysis reported a cost savings of $1.4 million. She said she doesn't know the reasoning behind a zero fiscal note for this iteration of the legislation, but would defer to the department on that matter. CO-CHAIR ZULKOSKY recommended that department representatives be available to speak about the potential cost savings at the next meeting, and presumed that there should still be a cost-savings as she didn't see a reason why it should change substantively since the analysis was done. 4:59:26 PM REPRESENTATIVE FIELDS asked Dr. Tomsen whether there would be any reason to not allow insurance coverage of emergency contraception provided by a pharmacist, without first requiring a patient to go to a doctor. He shared his understanding that if there is a need for emergency contraception, there would also be a tight timeframe, and asked why insurance coverage would not be accepted as payment. DR. TOMSEN responded that she agrees, but that the only difficulty is that many patients who seek to use emergency contraception do not want to talk to a pharmacist. She said that for this reason, over-the-counter availability is useful, and the patient can then use the receipt as proof to bill insurance. She shared that she is astonished that many patients were unaware that there is an improved emergency contraceptive [Ella] that insurance companies would pay for, but that the patient would need to go to the pharmacy window in order to obtain it. When patients understand that there is a better product that costs $60 out of pocket or covered if the patient has a prescription for it, she explained, the patients are usually interested in having the prescription available. She said that she doesn't see any reason why patients should have to pay for over-the-counter contraception, except that it has likely been a motivator for insurance companies. REPRESENTATIVE FIELDS added that he would be interested in pursuing an amendment to require that insurance companies pay for emergency contraception. [HB 58 was held over.] 5:02:22 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:02 p.m.