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At the Capitol May 22, 2018

MPhA Legislative Alert – Urge Governor Dayton to sign the Supplemental Finance legislation Now!

Many of you have been following the proceedings at the Minnesota legislature this year. On May 21, the legislature adjourned for the year and the end of the two-year session. With moments to spare, the Republican House and Senate sent Gov. Dayton several important pieces of legislation that he now has 14 days to sign or veto.

Two of the most consequential bills to Minnesota pharmacy and many other stakeholders across the State are the Omnibus Supplemental Finance bill SF 3656 and the final bill passed by both Houses of the legislature, 2018.0-ccrsf0799d. SF 3656 must be signed for SF 799d to be enacted. Both bills have been sent to Gov. Dayton, who now has 14 days to act (until midnight, June 3).

We need everyone’s help NOW to call and write emails to the governor urging him to sign both these bills TODAY!

Consequential pharmacy provisions of SF 3656 & SF 779d:

  • CMS Covered Outpatient Drug Rule for FFS Medicaid: pharmacy reimbursement rate, NADAQ + $10.48 and the 2% provider-wholesale tax fix; Task Force created to recommend to the legislature by February 1, 2019, a long-term solution to the outpatient prescription drug rule implementation.
  • Would prohibit Pharmacy benefit manager gag orders in pharmacy contracts in Minnesota.
  • Pharmacies required to provide patient with the lowest cost of medication at the point of sale (co-pay claw-back prohibited).
  • Patient refill medication synchronization allowed/PBM pharmacy contract prohibition eliminated.
  • Emergency fill and data input/output allowed remotely.
  • Minnesota Opioid Stewardship Council – includes MN pharmacy representative.

Please contact Gov. Dayton as soon as possible and let him know why this is so important to sign.

Example communication

Dear Governor Dayton:

On behalf of myself, XXXX Pharmacy and thousands of pharmacists and pharmacies as well as the patients we serve across Minnesota, I urge you to sign both the supplemental finance bill (SF 3656) and the related bill, SF 799d, that passed the House and Senate Sunday night.

These two bills, while not perfect, would ensure greater medication cost transparency by making sure that pharmacists are not prohibited from letting their patients know what is the lowest cost for the medication, even if it is out of pocket and outside their pharmacy benefit. The legislation would provide further transparency by requiring pharmacists to provide a patient the lowest cost for their medication, especially if their co-pay is higher than the actual drug cost. It would also allow for patients to synchronize their prescription drug refills, which currently is not allowed through many benefit plans in Minnesota.

Equally as important, and perhaps more so to local pharmacists throughout Greater Minnesota, is the interim fix for stakeholders affected by the CMS Covered Outpatient Drug Rule implementation. The State of Minnesota is currently out of compliance with the CMS Rule, as of April 2017. This is jeopardizing $190 million in Medicaid/Medical Assistance drug spend funding for the state’s most vulnerable citizens. It is also delaying the implementation of pharmacy reimbursement to a National Acquisition Cost model and the wholesale/provider tax – 2% reimbursement to be paid by MDH.

For all these reasons, I urge you to sign SF 3536 and SF 799d. Please do the right thing and sign these bills into law.

Sincerely,

XXXX

[*Make sure to include on letterhead if mailing or faxing. If emailing or calling, please identify yourself, your employer or affiliation and your home address.]

Governor Mark Dayton:
The Honorable Mark Dayton 
130 State Capitol 
75 Rev Dr. Martin Luther King Jr. Blvd. 
St. Pau, MN  55155

Email 
Send your questions and comments to Governor Dayton 

Telephone Numbers 
Telephone: 651-201-3400 
Toll Free: 800-657-3717 
Minnesota Relay: 800-627-3529 
Fax: 651-797-1850

At the Capitol May 18, 2018

As this update was written, both the House and Senate have yet to pass their massive Omnibus Finance spending bill that includes both policy for many stakeholders and supplemental funding adopted for all departments of the Minnesota state government. The Conference Committee met on Thursday night to hopefully pass the spending bill. However, there have been many indications that the governor will veto the bill — and then another round of negotiations will begin to come up with a spending bill he can support. This is all happening with four days left in the legislative session. The governor, in both his letters to the legislature, has stated that he does not need to sign a supplemental funding bill to make sure the government is functioning.

On May 16, the Minnesota Department of Human Services (MDHS) convened a conference call with stakeholders, including several representatives of Minnesota pharmacy, to let them know that the Centers for Medicare & Medicaid Services (CMS) has officially determined that Minnesota is out of compliance with the HHS-CMS Covered Outpatient Drugs Final Rule or the pharmacy outpatient reimbursement ruleand that in order to have Minnesota in compliance, action is needed now. Being out of compliance could potentially jeopardize millions of dollars in Medicaid drug spend funding for Minnesota.

Readers will recall that stakeholders, including Minnesota pharmacy, worked with the MDHS to come up with a consensus legislative pharmacy reimbursement proposal that would put the state in compliance with the rule; in the process, pharmacy reimbursement in Minnesota would move to a NADAC + $11.35 reimbursement rate. It also covered the 2% wholesale/provider tax donut hole on all fee-for-service MA prescriptions; without that, Minnesota pharmacists would dispense these fills at a substantial loss. The fiscal note associated with the implementation of the rule was estimated to cost approximately $3.8 million to the state annually. However, the MDHS is proposing a “revenue neutral” interim fix that would be adopted this week. It would have a NADAC +$10.48 reimbursement rate and would not include the 2% reimbursement language among other considerations to get to a “no-cost” solution.

This is unacceptable. We are working with the Minnesota Retail Association, the Minnesota Grocers Association, the National Association of Chain Drug Stores as well as other stakeholders to address our concerns. Minnesota pharmacy is opposed to the current proposal, but is working to find a solution much closer to the 2017 consensus reimbursement rate and language.  A letter has been sent this morning to Senator Rosen and Representative Knoblach outlining our concerns and encouraging them to include the 2% tax reimbursement.

Other provisions that are currently included in the Supplemental Finance Omnibus important to Minnesota pharmacy include:

  • Fair Practices/PBM contracting reform in the form of:
    • A gag-order prohibition;
    • Lowest cost of medication to the patient provided; and,
    • medication synchronization on refills allowed.
  • Pharmacist medication administration (IM/SubQ shots) for alcohol and opioid addiction treatment medications.
  • Emergency pharmacy fulfillment and remote data/systems access.
  • Statewide prescription drug repository established.
  • 30-day opioid prescription limit and 45 days on refills of opioids (schedule 2-4).
  • Opioid stewardship grant, pilot project, education and other various provisions (it is not known at the time of this writing if a manufacturer and wholesaler of opioids will see a fee as proposed in several bills including Senate Finance Chair Julie Rosen’s bill).
  • The bill does not include the language that would have authorized pharmacists in Minnesota to prescribe Naloxone, tobacco and smoking cessation medications as well as travel medications.
The legislature is constitutionally mandated to adjourn by Monday, May 21. Any legislation to be acted upon by the governor must be sent to him by midnight on Sunday, May 20. The governor already vetoed the House and Senate tax bill, calling for $180 million in “emergency school funding” before entering into any negotiations or signing a revised tax bill. On Wednesday, the Senate voted down the proposed bonding bill (a two-thirds vote is needed). There is much uncertainty around how the 2018 legislative session will come to a close.

At the Capitol May 1, 2018

The Minnesota legislature has 20 days left until they are mandated to adjourn by the State constitution. The Senate will take up their Omnibus Tax bill by the end of this week. The next two weeks (May 7th and May 14th) will be spent working on conference committee reports, the bonding bill, any tax conformity legislation that may be considered and several stand-alone bills.

  • The House passed the Health and Human Services (HHS) Finance Omnibus legislation on Tuesday, May 1:
    It includes gag order & claw-back pharmacy contracting reform, pharmacist emergency dispensing language, and much of the opioid crisis solution provisions, It does not include pharmacists prescribing or medication administration at this point. However, stakeholders, including MPhA, are still working hard to have one or both of these provisions included in the final HHS Omnibus legislation.
  • Early in the week, the Senate passed their Finance Omnibus bill which included all State government agencies and appropriations/supplemental budget legislative language. To date, neither pharmacy prescribing or medication administration have been included in the Senate legislation. However, the bills will not be finalized until they are conferenced in the next two weeks.

On Monday, April 30th, the Senate passed SF2836, Senator Jensen’s bill that would require that pharmacy benefit contracts with pharmacies do not prohibit a Minnesota pharmacist from providing their patients with the information on the lowest cost of medication. It also included language for the synchronization of patient medication refills in Minnesota.

Several provisions addressing the opioid epidemic in Minnesota were adopted as part of the Senate Finance bill earlier in the week. However, the Senate opioid stewardship fee and grant legislation, Senator Rosen's SF730, is still yet to see a floor vote. The good news is her opioid legislation had its final hearing in Senate Finance Committee on May 1st and was amended into final form for a Senate vote. The legislation would charge a licensing fee to opioid manufacturers and wholesalers operating in Minnesota based on the product volume distributed/sold of up to $20 million ($12million in aggregate from manufacturers; $8million in aggregate from the wholesalers). The fee revenue generated would fund a new Opiate Stewardship account; a special revenue fund that will pay for the Minnesota Dept. of Health grants as well as Prescription Monitoring Program upgrades.

Both the House (HF1440) and Senate bills also include limitations the number of days a schedule II-IV opiate prescription refill is valid (45 days in the House and 30 days in the Senate).  If the House or Senate is going to take up the opioid stewardship legislation, they will need support from House and Senate majority leadership. House leadership has indicated they are not interested in a new fee/tax and have included $10 million in appropriations from the State General Fund to address the opioid crisis. It is anticipated that both bills will pass their respective chambers and then be conferenced to determine what, if any, fee will be assed in Minnesota.

At the Capitol April 19, 2018

The Minnesota legislature spent the past week putting its finance bills together. Both the House and Senate are still working through their own legislative provisions that will ultimately be included in final House and Senate finance omnibus bills. The legislative process to move these bills to the House and Senate floor will be put together over the next two weeks. Significant action has been taken on several bills/provisions included in the omnibus legislation affecting Minnesota pharmacists and pharmacy.

Legislation, which has been modified at each committee stop along the way, would allow Minnesota pharmacists to prescribe in three medication categories. The bill was laid over for possible inclusion in the House HHS finance bill last week. However, the legislation has not been included in the current House omnibus legislation because it received a small fiscal note, meaning it costs the State to implement. While the legislation was heard and passed out of both House Committees it was referred to, there is still work to be done to find the funding to implement the legislation. In an April 19 House HHS Finance Committee hearing, the legislative language was offered as an amendment to the Finance Omnibus bill, but was then withdrawn because of the fiscal note. The fate of the pharmacists prescribing legislation in the House will most likely be decided in the next two weeks.

In the Senate, pharmacy prescribing did not receive a policy hearing before the spring recess; however, the bill may be brought up in the Senate Finance Committee during the conference committee process. Senate leadership and the authors of the legislation are working to have pharmacists prescribing in three medication categories included in the final finance legislation that will be conferenced between the House and Senate before the end of the Minnesota legislative session, which ends May 21.

Minnesota pharmacists prescribing:

Peterson, Baker; Jensen, Klein, Lourey, Rosen introduced:
HF 2962, SF 3015
A bill for an act relating to health; authorizing pharmacists to prescribe tobacco and nicotine cessation products, opiate antagonists and travel medications.

Minnesota pharmacists expanded medication administration legislation was introduced as a stand-alone bill in both the House and Senate early in the legislative session. Neither HF 3250 nor its companion, SF 3014, were heard in the HHS policy committees in the House and Senate. However, Rep. Baker, at the behest of several MPhA members, agreed late in the process to have the medication administration language (deletion) included in his opioid disposal bill that was heard by the House HHS Finance Committee.

The Medication administration amendment to Rep. Baker’s bill became controversial for several members of the HHS Finance Committee and was opposed by the HHS Finance DFL ranking member because the legislation was not heard in the House HHS Reform Committee, the House committee where all health care-related scope of practice legislation is to be heard. While the amendment was adopted and laid over for possible inclusion in the HHS Finance Omnibus legislation, there is still controversy surrounding this authority modification. The medication administration bill is less than likely to be included in the House bill.

In an effort to work with nursing interests as well as members who are concerned with a broad scope of practice change, the following amendment language has been offered and worked on as a compromise.

MN, 151.01, Subd. 27 to be amended to:
(4) participation in drug and therapeutic device selection; drug administration for first dosage and medical emergencies, except that, administration by subcutaneous or intramuscular injection or patch are not limited to first dosage and medical emergencies; drug regimen reviews; and drug or drug-related research;

Leadership and members of the House HHS Committee have committed to trying to include the amended language in any final finance bill. However, they have asked that more work be done to get the bill in the shape they desire in the House.

In the Senate, bill author Sen. Jensen has worked with Sen. Rosen (the Senate Finance Committee Chair and a great friend of pharmacy) over the past 10 days to include medication administration modifications in her legislation addressing the opioid crisis, SF 730. As of this update, there is a commitment by Senate leadership to adopt the medication administration amendment early next week.

Minnesota pharmacists expanded medication administration (original language/bills):
HF 3250; SF 3014, A bill to pharmacists license practice of pharmacy modified. Medication administration authority broadened.

Fair Practices and pharmacy contract reform legislation:
As was reported earlier during the legislative session, the Minnesota legislature has seen multiple bi-partisan bills introduced that would define fair practices for both the patient and pharmacists/pharmacies benefit contracts. Legislation supported by a broad coalition of providers, patient advocacy groups and the Minnesota pharmacist community was adopted by both the Senate and House HHS committees. It includes prohibitions in benefit contracts that prevent a pharmacist in Minnesota from informing patients when the co-pay from their insurance is more than the pharmacy’s cash price for the prescription (commonly referred to as gag order reform). The House also included legislative language that would compel prescription plans to charge patients the lower of usual benefit co-pay amount and the pharmacy’s usual and customary cash price. This provision, commonly referred to as claw-back prohibition, is included in the House legislation and is being heard this week as part of the House HHS Finance Omnibus legislation committee process.

While the Senate adopted similar language, that bill did not include the guarantee of lowest cost of medication to the patient. The Senate legislation includes gag order prohibitions and also includes provisions that would require plans to allow pharmacists and providers to synchronize medication refills (med-synch) and to pro-rate co-pays for prescriptions that are filled with a partial month supply for the purpose of synchronization. HF 3024 has been included in the House Omnibus Bill (HF 3138). SF 2836 will be voted on seperately in the Senate. The fair practices legislation will be included in both the House and Senate finance bills that will be conferenced later this session. There is a high level of confidence that these provisions will be enacted.

Dean; Jensen, Kiffmeyer, Sparks, Frenz
HF 3024; SF 2836
Health plan company prohibited from contractually preventing a pharmacist from informing a patient of a price differential.

Peterson, Hamilton, Zerwas, Gruenhagen and Freiberg; Jensen, Klein, Franzen, Utke, Nelson introduced:
HF 3012, SF 2596
A bill for an act relating to health; modifying payment for certain prescription medications; amending Minnesota Statutes 2016, section 151.71, by adding a subdivision. The bill was read for the first time and referred to the Committee on Health and Human Services Reform.

At the Capitol April 6, 2018

We have taken a significant step forward in making law, with the pharmacists prescribing authority language in House File 2692 and its companion Senate File 3015. In the House, the prescribing legislation took the next step to final passage. HF 2962 was heard in the House Health and Human Services Finance Committee where the bill was amended, received a fiscal note and ultimately was laid over for inclusion in the House HHS Finance supplemental budget bill that will be deliberated and put together after the Easter/Passover legislative recess. To summarize, the bill as amended has made it through all its stops in the House and will now move through the finance legislative process there.

HF 2962 would mean:
Pharmacists would be able to prescribe:

  • Opioid antagonist for the treatment of overdose – currently only Narcan/Naloxone (the Pharmacy Advocacy Task Force worked with the Steve Rummler Hope Foundation, Rep. Dave Baker and others);
  • Smoking cessation medications, excluding bupropion and only FDA approved (after working with ClearWay and the Minnesota Psychiatric Society);
  • Travel medications recommended by the CDC specifically for patients/residents traveling abroad (the MBOP protocol will maintain a specific list of these travel medications and update them periodically).

The final amendments included:

  • Provisions that tighten up the Travel Medication language in HF 2962 by including language that says:
    • “…"Travel medication" means a medication that is recommended by the federal Centers for Disease Control and Prevention for individuals traveling outside of the United States…”
  • Provisions that spell out how pharmacists are to be paid for services (in addition to the dispensing fee and product cost). The original bill language included a provision that would have stated all federal and state laws concerning insurance coverage would apply to prescribing under the bill. After receiving technical assistance from Chad Hope at the Minnesota Department of Human Services (DHS), the amendment language placed in MN 256b, under the Medication Therapy Management (MTM), a 9th qualifying service under MTM for MA coverage (fee for services & managed care) service will be covered.
    • “…#9) Prescribing products or medications as permitted under section 151.216, in accordance with standardized protocols developed by the board of pharmacy…” The health plans also agreed to this language and agreed with DHS, that paying for the pharmacist service would not increase costs.
  • A provision for Veterinary Emergency compounding: allows a pharmacist in Minnesota to compound and provide drug product for veterinary use without a specific patient prescription. (Rep. Roz Peterson authored for MBOP.)

This was after an amendment to the House bill last week that tightened up the tobacco cessation products provision by adding:

  • “…only FDA approved tobacco cessation medications… and excluding bupropion...” (includes Chantix).

HF 2962 is now in a very good place to be included in the House Finance Supplemental Omnibus bill that will ultimately be conferenced with a similar omnibus piece of legislation from the Senate. Sen. Julie Rosen, one of the authors of the pharmacist prescribing legislation, will put together the Senate Finance bill as Senate Finance Chair.

While the pharmacists prescribing legislation has made it through all policy and finance committees in the House, it was dealt a significant blow in the Senate last week. Senate HHS Finance Chair Michelle Benson indicated she will not hear the companion to HF 2962, SF 3015. While this does not “kill” the pharmacists prescribing legislation, SF 3015 did not meet second deadline in terms of making it out of the Senate HHS Finance and Policy Committee, the policy committee scope bills are heard in. Sen. Benson questions whether pharmacists should prescribe and also is keenly aware of opposition to the bill by the Minnesota Medical Association.

The legislation is not dead because it could be heard in Senate Finance, Sen. Rosen’s committee, and be included in the Senate Supplemental budget bill — where it could be conferenced with the House legislation. Even if it’s not included in the Senate Supplemental budget bill, it still could become part of the final Supplemental budget bill if the Senate and House conferees accept the House pharmacists prescribing legislation with the fiscal note of $14,000 in ’19 and $6,000 in the next biennium.

Only the next two months will tell the ultimate fate of the pharmacists prescribing legislation. The legislature is set to adjourn no later than May 21.

At the Capitol March 26, 2018

This past week, Pharmacy Advocacy Task Force co-chair, Jill Strykowski, and her colleague, Dr. Brian Sick, testified in support of Representative Roz Peterson’s HF2962/SF3015 before the Minnesota House Health and Human Services Reform Committee. Dr. Sick gave convincing testimony and urged members of the Committee to support the legislation that would have the Board of Pharmacy determine through protocol how pharmacists will be able to prescribe in three medication categories: opioid antagonist for the treatment of overdose, all tobacco cessation medications other than buproprion and travel medications recommended by the CDC and for use when traveling abroad.

After several questions for the testifiers and Representative Peterson, the House HHS Reform Committee members voted overwhelmingly to pass out of Committee HF2962 and send its final House committee before hopefully heading to the General Register, the House Floor. HF2962, the PATF legislation, will be heard on Tuesday, March 27th in Room 200 of the State Office Building (SOB) in the HHS Finance Committee. 

The companion legislation to HF2962 is not yet confirmed for a hearing in the Minnesota Senate, as of this update. However, we are optimistic that SF3015 will get heard by the legislature’s 2nd deadline, Thursday, March 29th.

SF3015 and SF3014 are bills that will go a long was to expanding health care access and increase patient adherence by utilizing one of the most trusted and often times, most convenient health professional - a Minnesota pharmacist to:

-SF3015: be able to prescribe in 3 medication categories - Naloxone, tobacco cessation medications and travel medications;
-SF3014: have the Minnesota Board of Pharmacy decide what medication administration pharmacists can offer to their patients.

There are several other important pharmacy bills moving through the Minnesota legislative process at the Capitol in St. Paul this week. HF3024 & HF3012 will go a long way to allow pharmacists to inform their patients of their medication purchasing options and require that the lowest allowable cost/price be offered to patients in Minnesota, even if it is the cash price.

Both these bills have made the 1st deadline by passing out of the House HHS Reform and Commerce & Regulatory Reform Committees this past week, however, only HF 3012, SF 2596 – gag order prohibited is currently scheduled in House HHS Finance for Wednesday, March 28th at 1:00 PM in Room 200 of the Senate Office Building. We anticipate HF 3012 being scheduled by March 30th.

These two bills will go a long way to rein in some of the egregious practices required in many pharmacy benefit manager contracts. SF2596 (gag order prohibited) was laid on the table for possible inclusion in the Senate HHS omnibus last week. Language providing for partial fill/medication synchronization for patients in benefit contracting was amended onto Dr./Senator Jensen’s SF2596 bill and is currently included in the Senate version of this bill. There are several access and affordability bills that are making their way through the Senate and the House and will probably be included in one final omnibus bill.

We are urging all MPhA members to contact their legislators and the Senate and House Chairs to encourage them to hear and support MPhA and Minnesota pharmacy legislation at the Capitol this week:

  • SF3015
  • SF3014
  • HF2962
  • HF3012

If you do not know who your legislators are, please see: Who Represents Me? Please continue to write your Representatives and Senators. PLEASE remember to carbon copy HHS Chairs, Senator Benson and Representative Dean.

Senate HHS Policy and Finance Chair, Michelle Benson:
Michelle R. Benson (31, R)
3109 Minnesota Senate Bldg.
95 University Avenue W.
St. Paul, MN 55155
651-296-3219

House HHS Finance Committee Chair:
Matt Dean (R) District: 38B
401 State Office Building
100 Rev. Dr. Martin Luther King Jr. Blvd.
St Paul, MN 55155
651-296-3018
E-mail: rep.matt.dean@house.mn

At the Capitol March 23, 2018

The Pharmacy Advocacy Task Force — a coalition made up of members from MPhA, the Minnesota Society of Health-System Pharmacists (MSHP), The Minnesota College of Clinical Pharmacy (MCCP), The Duluth Area Pharmacists and the University of Minnesota College of Pharmacy — continues its review of the pharmacy practice act with the intent of advancing legislation that removes barriers to the expansion of pharmacy practice.

Currently, two companion bills have been introduced.

These bills aim to improve patient access to critical medications in three categories by allowing pharmacists to prescribe these through a statewide protocol. The three medication categories are naloxone, tobacco cessation medications, and travel medications.

Good News!

Tuesday evening (3/20/18), HF 2962 received a hearing in the Health and Human Services Reform Committee and has passed.

What We Need Now

  • TODAY: We need pharmacists, pharmacy technicians, and friends of pharmacy to call and/or email their MN Senator today and ask them to request a committee hearing for SF 3015! It has been referred to the Senate Health and Human Services Finance and Policy Committee (Chaired by Senator Michelle Benson). Please share with pharmacy staff at your site, as we need to have a first hearing scheduled ASAP or the legislation dies. Use the information provided below to craft your message.

I am writing to ask that you please help ensure SF 3015 receives a Senate committee hearing.

This bill (along with companion HF 2962, which passed the Health and Human Services Reform Committee) aims to improve patient access to critical medications in 3 categories by allowing pharmacists to prescribe these through a statewide protocol.

We know that:

  • Opioids have killed more than 2,700 Minnesotans in the last 15 years. Most of these deaths involved prescription drug use. The pharmacist is very accessible and has a chance to intervene and provide a life-saving medication.
  • According to the MDH, smoking causes 5,900 deaths each year in MN. Pharmacist intervention has been shown to increase smoking cessation rates by 12.5%.
  • International tourism continues to grow. A large portion of our population in MN has family roots outside of the United States, resulting in frequent travel. Assuring access to appropriate vaccinations and travel medications can protect our citizens from diseases that are still common outside of the U.S. Improving access to these medications will impact all Minnesotans.

Use of the medications above does not require a diagnosis and is a matter of choice for the patient, so prescribing these are within the scope of a pharmacist's practice. In the 8 years of training to obtain a doctorate degree in pharmacy, pharmacists obtain extensive clinical knowledge and become experts in medication therapy management.Pharmacists are often the first (and sometimes only) access that patients utilize to the healthcare system. Often, patients may be more comfortable in sharing the need for these medications with their pharmacist vs. other health professionals.

At the Capitol March 15, 2018

Long-time Minnesota Pharmacists Association member Eric Slindee of Sterling Pharmacy testified before the Minnesota House Health and Human Services Reform Committee on behalf of all pharmacy in Minnesota in support of two bills, H.F. 3012 and H.F. 3024. The first bill would prohibit benefit contracts provisions that don’t allow a pharmacist to inform their patients about the lowest cost of medications and potentially much more affordable medication options even if for a cash purchase of medications outside of benefit networks if that option is less expensive.

The second bill would prohibit pharmacy benefit manager and insurer pharmacy contracts from requiring an individual (patient) make a payment in an amount greater than the allowable cost to consumers, as defined by (1) the applicable co-payment for the prescription medication, (2) the allowable claim amount for the prescription medication, or (3) the amount an individual would pay for the prescription medication if the individual purchased the prescription medication without using a health plan benefit. This would ensure that the patient is only paying the lowest amount possible for the medication they seek, even if that price is lower than their co-pay or Usual and Customary price.

Please call, write or email your legislator today and ask them to support the following two bills that will next be headed to the Minnesota House Commerce Committee:

Peterson, Hamilton, Zerwas, Gruenhagen, Frieberg and Liebling; Jensen, Klein, Franzen, Utke, Nelson introduced:
HF 3012, SF 2596
A bill for an act relating to health; modifying payment for certain prescription medications; amending Minnesota Statutes 2016, section 151.71, by adding a subdivision. The bill was read for the first time and referred to the Committee on Health and Human Services Reform.

Dean, Loonan; Jensen, Kiffmeyer, Sparks, Frenz
HF 3024; SF 2836
Health plan company prohibited from contractually preventing a pharmacist from informing a patient of a price differential.

In addition to these two bills, Representative Roz Peterson as well as Senator Jensen Chief authored and introduced HF 3783 that when enacted would provide reasonable fair practice protections for patients that allow pharmacists to provide the best care and advice at the lowest costs to patients. These provisions would also ensure greater patient choice and access which leads to greater adherence and better health outcomes.

  • Pharmacy delivery service restrictions. This would require a PBM to allow a community pharmacy to deliver or mail a reasonable number of prescriptions to their customers, maintain the patient-pharmacist medication management relationship, while still allowing the PBM to prevent a pharmacy from setting up a full-blown mail-order pharmacy.
  • Anti-mandatory mail order. This would prohibit a PBM from requiring patients to use mail order for their prescriptions. These provisions still allow for financial or other incentives for using the PBM’s mail order.
    • Partial fill/medication synchronization for patients.

We are still hoping that the legislature will hear and act on the following bills and we urge you to contact your Senator and Representative to ask them to support and call for a hearing on:

Peterson, Hamilton, Zerwas, Gruenhagen and Freiberg; Jensen, Klein, Franzen, Utke, Nelson introduced:
HF 3011, SF 2598
A bill for an act relating to health; prohibiting the use of incentives or disincentives for using certain pharmacies; amending Minnesota Statutes 2016, section 151.71, by adding a subdivision. The bill was read for the first time and referred to the Committee on Health and Human Services Reform

Hamilton, Zerwas and Gruenhagen; Jensen, Klein, Franzen, Utke introduced:
HF 2950, SF 2597
A bill to enact legislation relating to insurance; providing for the licensing of pharmacy benefit managers; amending Minnesota statutes 2016, section 60A.23. This bill was referred to the House and Senate Commerce Committees.

PATF legislation:
Peterson, Baker; Jensen, Klein, Lourey, Rosen introduced:
HF 2962, SF 3015
A bill for an act relating to health; authorizing pharmacists to prescribe tobacco and nicotine cessation products, opiate antagonists, and travel medications; amending Minnesota Statutes 2016, section 151.01, subdivisions 23, 27, by adding a subdivision; proposing coding for new law in Minnesota Statutes, chapter 151.

HF 3250; SF 3014, A bill to Pharmacists license practice of pharmacy modified. Medication administration authority broadened.

We are also watching and providing input to legislators and the authors of several legislative proposals related to the opioid crisis. One of the bills, Senator Rosen’s SF 730, would place an Opiate Stewardship fee (some say tax) on manufacturers and wholesalers of opioid medications. It would also require pharmacists to report monthly the previous month’s deliveries and distributions of opioid medications and would create an Opiate Stewardship Advisory Council.

Here is how the fee would be calculated:

The board must calculate the fee that is to be paid by each manufacturer by using a base rate for all drugs listed in subdivision 1, and multipliers of the base rate for certain drugs and dosage forms as specified in this subdivision.

(b) The base rate shall be $0.01 per unit distributed or dispensed. A unit is each capsule, tablet, milliliter, gram, or other such amount, as defined by board.
(c) An active ingredient multiplier of 10 shall be applied to the base for schedule II opium derivatives and opiates, as defined in section 152.02, subdivision 3, except as further defined below:
(1) oxycodone: 15; (2) oxymorphone: 15; (3) hydromorphone: 15; (4) methadone: 20; and (5) fentanyl: 20.
(d) In addition to the active ingredient multiplier, a dosage form multiplier shall be applied to the base as follows:
(1) liquid: 0.2; and (2) patch: 20.

House and Senate leadership are opposed to a new tax at this time. Stakeholders, including MPhA, have weighed in with Senator Rosen and legislators to let them know the current proposal could increase by two to three fold opioid medication costs and that the fee will ultimately be paid by the patient/consumer.


At the Capitol March 4, 2018

The Minnesota legislature convened February 20 and went straight to work on the bonding or short year of the two-year session. The House and Senate quickly put a period on the end of the 2017 session by passing the Legislature’s 2018-19 budget that Gov. Mark Dayton vetoed last May. The 2018 legislative session was met with a new wrinkle when US Sen. Al Franken resigned in early January and Gov. Dayton appointed his Lt. Gov., Tina Smith, to fill out the US Senate term until the next election can fill the seat.

Because Lt. Gov. Smith is now Sen. Smith, the Minnesota Constitution clearly indicates that the President of the Minnesota Senate, in this case Sen. Michelle Fischbach, shall ascend to become the lieutenant governor when there is a vacancy. The Constitution is not so clear on whether the lieutenant governor can serve as a state senator at the same time. This question still remains. As of this update the lieutenant governor has acted in her capacity as both a state senator and the President of the Senate while being lieutenant governor for the past two and a half weeks.

The Ramsey County Court, where a case had been filed by a constituent of Sen. Fischbach prior to the start/reconvening of the legislative session this year, said the case “wasn’t ripe.” It is not clear if the case has now ripened since the senator has taken a vote as a member of the Legislature while she is at the same time acting in her capacity as lieutenant governor. This is all critical because the Minnesota Senate stands at a 34-33 seat majority for the Republicans. If the Court would rule that Sen. Fischbach cannot serve in both branches/both capacities, it could open her seat for a special election being called and presumably a 33-33 tie in the Senate would occur. Stay tuned…

For the month of March, the legislature is focused on hearing bills introduced this year and last year and moving them through the legislative process. The first committee deadline is March 22, the second deadline is March 29, and the third deadline is April 20. Bills must be heard and passed out of one house by the first deadline, both houses by the second deadline and clear any necessary Finance Committees by third deadline to be considered this session.

Pharmacy:

Legislative Day and the PATF Agenda

On Feb. 27, MPhA – in conjunction with the Minnesota Society of Health-System Pharmacists (MSHP), the Minnesota Retailers Association (MnRA), the Minnesota Grocers Association (MGA) and the Pharmacy Advocacy Task Force (PATF) – had its most successful Legislative Day in recent memory. Nearly 200 pharmacists and student pharmacist participants made over 75 visits. The meetings were a huge success, including getting commitments from Sens. Scott Jensen (R) and Matt Klein (DFL), both physicians, to chief and co-author the PATF legislation that will be introduced the week of March 5 in the Senate as a companion to the PATF legislation recently introduced in the House, HF2962. The key distinction between HF 2962 and HF1140 (PATF legislation introduced last year) is, HF2962 does not include the hormonal contraceptive prescribing authorizing language. The legislation and its companion in the Senate call for prescribing authority for pharmacists in three medication categories: naloxone, smoking cessation medications and travel medications.

Medication Administration

The same Senate co-sponsors have also agreed to co-author legislation that would provide for broad medication administration for pharmacists in Minnesota, another priority of the PATF. Reps. Roz Peterson (R) and Dave Baker (R) introduced the companion medication administration expanded authority for pharmacists in the House, HF3250 (check back for updated Senate bill numbers soon).

Patient Fair Practices/PBM Reform

Additionally, several bills that are gaining steam and beginning to gather a lot of attention were introduced in the House and Senate; they would protect patients and pharmacists from unfair practices by health insurers and pharmacy benefit managers (PBMs).
The legislation would, among other things, prohibit gag orders that don’t allow pharmacists to provide patients with the least expensive medication information and PBM co-payment take-backs, provide for PBM incentives reform; one bill would provide PBM transparency requirements and regulation by the Minnesota Department of Commerce (Minnesota’s insurance regulator). For the first time, legislation introduced would also put in law the right for patients to choose a local pharmacy for their medications instead of mail-order or specialty medication pharmacy, often owned by a PBM, now required by many pharmacy benefit contracts/plans.

Current Activity

Additional co-sponsors in the House and Senate for both PATF bills as well as fair practices form will be sought over the coming days and weeks. The PATF prioritized legislation and all but the Department of Commerce-PBM regulation bill have been referred to the House and Senate Health and Human Services Committees, where the legislation will need to be heard and passed out of before either heading to an additional committee(s) before being sent to the House or Senate floors.

CALL TO ACTION:

PLEASE call or write your Senator or Representative today - Who Represents Me? - Use the district finder to retrieve a list of your representatives with contact information. Ask them to support and co-sponsor the PATF legislation (HF2962/SF3015 & HF3250/SF3014). Also, please ask them to support patient and pharmacy fair practice protections!

If you have any questions, please email PATF and MPhA Lobbyist Buck Humphrey at hubert4@gmail.com or MPhA Interim Executive Director Marsha Millonig at marsham@mpha.org.

PATF legislation:

Peterson, Baker; Jensen, Klein, Lourey, Rosen introduced:
HF2962, SF3015
A bill for an act relating to health; authorizing pharmacists to prescribe tobacco and nicotine cessation products, opiate antagonists, and travel medications; amending Minnesota Statutes 2016, section 151.01, subdivisions 23, 27, by adding a subdivision; proposing coding for new law in Minnesota Statutes, chapter 151.

HF3250; SF3014, A bill to Pharmacists license practice of pharmacy modified. Medication administration authority broadened.

Patient Fair Practices/PBM Reform Bills:

Peterson, Hamilton, Zerwas, Gruenhagen, Miller and Freiberg; Jensen, Klein, Franzen, Utke, Nelson introduced:
HF3010, SF2599
A bill for an act relating to health; prohibiting penalties to pharmacists for sharing certain information with individuals; amending Minnesota Statutes 2016, section 151.214, by adding a subdivision.The bill was read for the first time and referred to the Committee on Health and Human Services Reform.

Peterson, Hamilton, Zerwas, Gruenhagen and Freiberg; Jensen, Klein, Franzen, Utke, Nelson introduced:
HF3011, SF2598
A bill for an act relating to health; prohibiting the use of incentives or disincentives for using certain pharmacies; amending Minnesota Statutes 2016, section 151.71, by adding a subdivision. The bill was read for the first time and referred to the Committee on Health and Human Services Reform.

Peterson, Hamilton, Zerwas, Gruenhagen and Freiberg; Jensen, Klein, Franzen, Utke, Nelson introduced:
HF3012, SF2596
A bill for an act relating to health; modifying payment for certain prescription medications; amending Minnesota Statutes 2016, section 151.71, by adding a subdivision. The bill was read for the first time and referred to the Committee on Health and Human Services Reform.

Zerwas, Hamilton, McDonald and Peterson; Jensen, Nelson, Draheim, Wiklund introduced:
HF3016, SF2669
A bill for an act relating to health care; prohibiting a health plan company from contractually preventing a pharmacist from informing a patient of a price differential; amending Minnesota Statutes 2016, section 151.214. The bill was read for the first time and referred to the Committee on Health and Human Services Reform.

Hamilton, Zerwas and Gruenhagen; Jensen, Klein, Franzen, Utke introduced:
HF2950, SF2597
A bill to enact legislation relating to insurance; providing for the licensing of pharmacy benefit managers; amending Minnesota statutes 2016, section 60A.23. This bill was referred to the House and Senate Commerce Committees.


The 2018 Legislature – Pharmacists: Part of the Solution

The Minnesota House and Senate legislative session was gaveled in on Tuesday, Feb. 20. The start of the second year of the Minnesota Legislative Session is known as the “short” and/or “bonding” session/year. The legislature must adjourn by May 21. Only the Governor can call the legislature back into a special session after the May adjournment date. (The state constitution limits the legislature to meeting 120 legislative days during each biennium. In addition, the legislature may not meet in regular session after the first Monday following the third Saturday in May of any year.)

Uncertainties

There are many uncertainties as we head into the 2018 session. First, the legislature must pass and the Governor sign into law the legislature’s biennial budget. The Governor, in an attempt to force the Legislature back to the negotiating table, line-item vetoed the funding after the legislature adjourned in 2017. It appears that the Governor and the legislature have agreed the first order of business will be to pass and sign into law a clean funding bill for the legislature.

Gov. Dayton’s appointment of Lt. Gov. Tina Smith to Sen. Al Franken’s seat has created a new constitutional crisis for the Minnesota Legislature. According to the Minnesota Constitution, current Senate President and GOP Sen. Michelle Fischbach is now the Lieutenant Governor. There are differing opinions on whether Sen. Fischbach may retain her senate position and serve as Lieutenant Governor. A case was filed in the courts making the case she could not serve in both roles, however, the courts have said the case “is not ripe” because Lt. Gov. Fischbach has not yet taken a vote in the Senate. It is the Senator’s intention to do both and likely the Senate DFL’s intention to force the courts to decide whether that decision is legally sound.

Currently, the GOP controls the Minnesota Senate by a 34-33 margin after a special election DFL victory in early February to retain Sen. Dan Schoen’s seat, which he resigned last fall. Because the DFL retains the seat, the one-seat margin could move the Senate temporarily into a 33-33 tie, if the court says Lt. Gov. Fischbach cannot serve in both capacities. Presumably in this case, a special election would be necessary to fill the Fischbach seat. Given the likelihood the issue will be resolved by the courts, it’s not likely the seat would be filled until later in the 2018 Session. A 33-33 tie would likely throw the 2018 session into complete turmoil. Hopefully, this is all resolved soon.

This is all to say that there are a number of moving pieces — but with all things being equal and a Legislative Session going forward as planned, the Legislature will adjourn in late May.

The Pharmacy Advocacy Taskforce (PATF) Agenda:

This year the PATF is putting on a full-court press to help Minnesota pharmacists have the opportunity to practice at the top of their license. We hope to have a hearing, see movement and hopefully enactment of legislative proposals that the PATF is advocating for. The PATF’s legislative agenda includes:

Pharmacists Expanding Healthcare Access: Legislative Summary: MN HF1140SF1049

EXPANDING PATIENT ACCESS TO CARE:

Amid growing concern about lack of access to primary care providers, pharmacists are an untapped resource. Underserved populations have many barriers to receiving adequate health care needs, such as transportation and cost. Rural and economically disadvantaged urban areas have less than half the rate of primary care physicians as wealthier urban areas, meaning that patients often have to travel long distances or wait for months to see their doctor. Ninety‐three percent of Americans live within five miles of a community pharmacy, many of which are open 12 to 16 hours a day, seven days a week. According to the World Health Organization:

“Community pharmacists are the health professionals most accessible to the public.”

OPIOID ANTAGONISTS

Opioids have killed more than 2,700 Minnesotans in the last 15 years. More than 80% of these deaths involved prescription drugs, and nearly 60% have occurred in the past 5 years. There were 355 deaths in 2015 and a 31% increase in 2016. Hennepin County saw a record 144 opioid‐related deaths in 2016. A study by the National Bureau of Economic Research found that legislation that expanded the access of naloxone to the public was “associated with a 9 to 11 percent reduction in opioid‐related deaths....” This study also states that there was “little evidence that these laws increase the recreational use of prescription painkillers.” Increased access to naloxone can save lives.

HORMONAL CONTRACEPTIVES

In Minnesota in 2010, the federal and state governments spent $332.6 million on unintended pregnancies; of this, $203.9 million was paid by the federal government and $128.7 million was paid by the state. The total public costs for unintended pregnancies in 2010 was $318 per woman aged 15-44 in Minnesota, compared with $201 per woman nationally. Increasing the scope of pharmacist practice to prescribe oral hormonal contraceptives can increase access to care for many patients, and help reduce the negative effects of unintended pregnancies on an individual and community level by removing unnecessary and inefficient barriers.

TOBACCO CESSATION TREATMENT

According to the Minnesota Department of Health, smoking causes 5,900 deaths and over $2.5 billion in medical costs every year in Minnesota. A study found that community pharmacist intervention led to a 12.7% increase in smoking cessation rates through interventions related to nicotine replacement.

TRAVEL MEDICATIONS

International tourists are estimated to reach 1.6 billion by 2020, with an increasing proportion visiting the developing world. Providing Minnesota pharmacists with the ability to prescribe medications according to the CDC for travel abroad would enhance access to recommended medications and be a practical convenience for thousands of Minnesotans. It also will help Minnesotans stay healthy while traveling and returning home. Travel medications include: vaccines, medications for traveler’s diarrhea and malaria prevention.

Medication Administration:

We are seeking changes to Minnesota pharmacy medication administration law. A bill will be introduced the first week of session with changes that would provide Minnesota pharmacists with broader authority to administer medications. Currently in Minnesota, pharmacists can only provide prescription drug medication administration for first dose and on an emergency basis. Minnesota pharmacists can also provide vaccinations. However, unlike in 29 other states, pharmacists in our state cannot provide pharmacy-based medication administration services (MAS). Pharmacy-based MAS improves public health by facilitating patient access to care, supporting patients with improved access to needed services, decreasing stigma, and enhancing collaboration with the health care team.

Patients who can benefit from MAS may encounter challenges such as scheduling conflicts with prescribers, difficulty with medication adherence, and a lack of knowledge of the medication or administration of the medication. In the provision of MAS, pharmacists meet with patients regularly to provide education on medications, help patients manage all prescribed medications, support interventions that improve the quality of care, engage as part of the health care team, and ensure that patients are receiving the expected benefits from treatment. Pharmacy-based MAS can also assist patients who struggle with self-injection by providing initial education and support on medication self-administration, ensuring appropriate follow-up to monitor proper technique, reporting any adverse events, and addressing barriers to adherence.

The PATF, in conjunction with MPhA, has begun meeting with and educating legislators about our legislative agenda and learning about House and Senate member priorities for the session. Feb. 27 is Pharmacy Legislative Day at the Capitol in St. Paul. We hope to have as many pharmacist attendees as possible meet with a majority of the legislative members on the Senate and House Health and Human Services Committees.

Other Impactful Legislation:

Thousands of bills are introduced each session; only a small percentage of those proposals will impact Minnesota pharmacy. Here are several of the bills and executive branch initiatives we are following during the session this year.

SF593/HF747 [Hamilton/Nelson]: Prescription Drug Coverage Prior Authorization; drug transparency and disclosure requirement. The prior authorization bill would, among other things, prohibit “mid-year” drug switching by health plans and/or their PBMs. In the Senate, the HHS Policy and Finance Committee laid the bill over last year for possible inclusion in the Senate Finance Omnibus. It was not included. The bill was not heard in the House Commerce Committee, where it has been referred. Technically it’s still alive, but at this point it does not look like the proposal will make it through the House this year.

SF1509/HF1819 [Zerwas/Abler]: The legislation that contains the pharmacist reimbursement rate increase and Medicaid decrease was heard and passed out of both the Senate and House and was included in the final Senate HHS Finance Omnibus legislation, SF 800, which was ultimately vetoed. Although the bill was also included in the Governor’s supplemental ’17 budget, it did not make the final negotiation cuts to the HHS Finance bill. Also, there is a fiscal note of $4.7 for the ‘17-18 biennium and tails for the ‘19-20 biennium. We assume there will be a supplemental budget bill this year, but what will include is not known. We have made it clear to Committee staff and members that we want to see the reimbursement rate changes passed last year enacted this year.

State law makers and the public want to do something, anything, to try to reverse the trends in addiction and overdose deaths; this issue is front and center as session begins. The Governor and a bipartisan group of lawmakers have proposed a package to help bring relief to affected Minnesotans. The proposal includes a “penny per pill” tax (the current proposal would be a tax per pill to the manufacturer at a graduated rate based on quantity). The proposal would generate approximately $20 million a year. Those dollars would be spent on treatment services, wide distribution of naloxone and potentially pay for needed technical upgrades to the current PMP. There are several other ideas about how to tackle the opioid crisis at the legislature left over from last year and yet to be proposed this session.

Here are the opiate related bills that are currently introduced that have some chance of passing:

  • HF1440/SF730: Opiate stewardship program established, report required, and money appropriated. (Baker/Rosen) Hearings last week, laid over for inclusion in the Senate Omnibus bill; this was the milligram tax bill that was introduced last year. While the milligram tax idea is out, the penny per pill idea is in and moving.
  • HF1219/SF843: Minnesota prescription monitoring program restrictions on a prescriber's authority to prescribe controlled substances identified. (Baker/Eaton)
  • HF1136/SF750: Naloxone standing orders compliance required. (Baker/Eaton)
  • HF 1137/SF753: Requires check of the PMP. At the end of last year in the House, Rep. Baker removed the requirement for pharmacists, only requiring prescribers to check. Also, Rep. Peggy Scott refused to hear the bill in the Civil Law and Data Practices Policy Committee or let it be referred to another committee, so unless this has changed, this bill most likely will not move.
  • HF2066/SF1868: Opiates prescribed for acute dental and ophthalmic pain quantity limits placed. (Baker/Benson)
  • HF 0897/SF795: Requires all pharmacies to maintain pharmaceutical waste collection receptacles. Rep. Baker has now said he may revive this in the House if there is a source of revenue to fund a program run potentially by the Board of Pharmacy as it is in Iowa and North Dakota. We did not see this proposal move in the Senate last year; however with a potential new source of revenue (from the opioid tax) we could see this legislation/idea move forward.

Finally, the legislature may be poised to act on reforms proposed to protect patients and providers from unfair Pharmacy Benefit Managers (PBMs) practices and policies. Growing frustration with pharmacy benefit managers, health insurers and pharmaceutical companies has driven legislators of all stripes as well as Gov. Dayton to call for reforms to our current health care system. The 2017 Session began with a hearing in the House Health and Human Services Finance Committee on health care network access and the Senate looked poised to pass prior-authorization protections/reform, but ultimately meaningful reforms did not occur in 2017.

Over the past 7 months, Sens. Jensen and Klein have led a senate effort to examine health care access and affordability with their colleagues. We don’t know yet what, if anything, will come from the Select Committee on Affordability and Accessibility’s deliberations this past summer and fall. Last year, Sen. Jensen introduced bipartisan legislation to ensure any health care provider willing to agree to the same contractual terms and conditions as in-network providers would be guaranteed access to the network for their patients. The legislation did not receive a vote in committee, but started a conversation and debate about the rights of patients and their providers versus insurer and payers of health care services and medications.

The Minnesota Legislature’s focus on the topic over the past 12 months has grown acute with the level of mistrust and anger voiced by patients toward their insurers (including the State of Minnesota). Constituents of rural legislators are voicing concerns about limited access to care and challenges getting their prescriptions from their local pharmacy.

Some legislators, such as Reps. Hamilton and Peterson, believe Minnesotans have grown tired of being told by their insurers they have to switch medications prescribed by their doctors mid-year, pay high deductibles, multiple co-pays or more for their medications in-network than they could pay with cash down the street. They have also been mandated to receive their medications from mail-order specialty pharmacies owned by their insurers and providers are being limited and regulated by insurers in terms of treatment, diagnosis and medication options.

All this is having an undesirable effect on patient health outcomes as well. However, while it appears that the legislature will move forward this year to broaden access and rein in affordability, there are still powerful interests — and legislators who support those interests — standing in the way of legitimate reform legislation. As a consequence, no significant patient protections have made it to either floor of the House or Senate in the past 3 years. In addition, state agencies such as DHS have sided with insurers in terms of the “cost” debate surrounding these proposals. To date, all patient and provider protections in proposed legislation have been issued a fiscal note with fairly significant cost estimates to the state. We will see if 2018 is any different.

There are and will be additional bills that surface that may affect Minnesota Pharmacy. We will be sure to add those bills to our next update. Look for another legislative update as we approach committee deadlines in March. If you have any questions or would like to get in touch with our PATF Government Affairs representative, Buck Humphrey, he can be reached at:
hubert4@gmail.com, 612.889.6515.

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