25 LC 57 0203
House Bill 196
By: Representatives Kelley of the 16
th
, Taylor of the 173
rd
, Hatchett of the 155
th
, Hugley of
the 141
st
, Jasperse of the 11
th
, and others
A BILL TO BE ENTITLED
AN ACT
To amend Part 1 of Article 1 of Chapter 18 of Title 45 of the Official Code of Georgia
1
Annotated, relating to state employees' health insurance plan, so as to require that drugs2
dispensed to a covered person for self-administration under a state health plan be reimbursed3
using a transparent, index based price, plus a dispensing fee; to provide for definitions; to4
provide for related matters; to repeal conflicting laws; and for other purposes.5
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA: 6
SECTION 1.7
Part 1 of Article 1 of Chapter 18 of Title 45 of the Official Code of Georgia Annotated,8
relating to state employees' health insurance plan, is amended by adding a new Code section9
to read as follows:10
"45-18-22.
11
(a) As used in this Code section, the term:12
(1) 'Georgia estimated acquisition cost and select specialty pharmacy rates' means this13
state's monthly average drug acquisition cost as of the first day of each month as14
determined by the Department of Community Health.15
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(2) 'Insurer' means a corporation licensed to transact accident and sickness or major16
medical insurance business in this state, a healthcare corporation, a health maintenance17
organization, a pharmacy benefits manager, or any other entity that provides healthcare18
coverage or services pursuant to a state health plan.19
(3) 'National average drug acquisition cost' means the monthly survey of retail20
pharmacies conducted by the federal Centers for Medicare and Medicaid Services to21
determine average acquisition cost for Medicaid covered outpatient drugs.22
(4) 'Pharmacy' means a pharmacy or pharmacist licensed or holding a nonresident23
pharmacy permit pursuant to Chapter 4 of Title 26.24
(5) 'Pharmacy benefits manager' means a person, business entity, or other entity that25
performs pharmacy benefits management as such term is defined in Chapter 64 of26
Title 33. The term 'pharmacy benefits manager' includes a person or entity acting for a27
pharmacy benefits manager in a contractual or employment relationship in the28
performance of pharmacy benefits management for a health plan, including operating or29
administering a prescription card or prescription discount program directly or on behalf30
of a pharmacy benefits manager or insurer for covered persons for drugs not covered or31
being reimbursed by the covered person's pharmacy benefits manager or health plan. 32
Such term shall not include services provided by pharmacies operating under a hospital33
pharmacy license. Such term shall not include health systems while providing pharmacy34
services for their patients, employees, or beneficiaries, for indigent care, or for the35
provision of drugs for outpatient procedures. Such term shall not include services36
provided by pharmacies affiliated with a facility licensed under Code Section 31-44-4 or37
a licensed group model health maintenance organization with an exclusive medical group38
contract and which operates its own pharmacies which are licensed under Code Section39
26-4-110.40
(6) 'State health plan' means:41
(A) The state employees' health insurance plan established pursuant to this article;42
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(B) The health insurance plan for public school teachers and the health insurance plan43
for public school employees established pursuant to Subparts 2 and 3, respectively, of44
Part 6 of Article 17 of Chapter 2 of Title 20; and45
(C) The health benefit plan established for members, employees, and retirees of the46
Board of Regents of the University System of Georgia pursuant to Code Section 31-2-4.47
(b) On and after January 1, 2026, an insurer shall reimburse a pharmacy for a drug48
dispensed to a covered person for self-administration in the state health plan in an amount49
equal to:50
(1) The national average drug acquisition cost on the day of claim administration or, if51
unavailable, the rate provided in the Georgia estimated acquisition cost and select52
specialty pharmacy rates on the day of claim administration or, if unavailable, the53
wholesale acquisition cost on the day of claim administration;54
(2) An amount equal to 4 percent of the amount determined in accordance with55
paragraph (1) of this subsection, or $50.00, whichever is less; and56
(3) A professional dispensing fee that is not less than the professional dispensing fee paid57
by the state under Title XIX of the Social Security Act.58
(c) An insurer shall calculate a beneficiary's cost share or deductible based solely on the59
ingredient cost of a prescription drug and shall be prohibited from passing along the cost60
of the professional dispensing fee to a beneficiary through a cost share, deductible, or any61
other out-of-pocket payment by the beneficiary.62
(d) An insurer shall not circumvent the requirements regarding pharmacy reimbursement63
in this Code section in any manner, including without limitation by adjudicating claims64
through a prescription drug discount card or program.65
(e) In addition to any other remedy provided by law, a violation of this Code section by66
an insurer shall give rise to a private right of action for damages and equitable remedies for67
the pharmacy or beneficiary aggrieved."68
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SECTION 2.
69
All laws and parts of laws in conflict with this Act are repealed.70
H. B. 196
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