25 LC 57 0229S
The House Committee on Health offers the following substitute to HB 196:
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 Georgia1
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. Such term shall not include any19
licensed group model health maintenance organization with an exclusive medical group20
contract and which operates its own pharmacies which are licensed under Code21
Section 26-4-110.22
(3) 'National average drug acquisition cost' means the monthly survey of retail23
pharmacies conducted by the federal Centers for Medicare and Medicaid Services to24
determine average acquisition cost for Medicaid covered outpatient drugs.25
(4) 'Pharmacy' means a pharmacy or pharmacist licensed or holding a nonresident26
pharmacy permit pursuant to Chapter 4 of Title 26.27
(5) 'Pharmacy benefits manager' means a person, business entity, or other entity that28
performs pharmacy benefits management as such term is defined in Chapter 64 of29
Title 33. The term 'pharmacy benefits manager' includes a person or entity acting for a30
pharmacy benefits manager in a contractual or employment relationship in the31
performance of pharmacy benefits management for a health plan, including operating or32
administering a prescription card or prescription discount program directly or on behalf33
of a pharmacy benefits manager or insurer for covered persons for drugs not covered or34
being reimbursed by the covered person's pharmacy benefits manager or health plan. 35
Such term shall not include services provided by pharmacies operating under a hospital36
pharmacy license. Such term shall not include health systems while providing pharmacy37
services for their patients, employees, or beneficiaries, for indigent care, or for the38
provision of drugs for outpatient procedures. Such term shall not include services39
provided by pharmacies affiliated with a facility licensed under Code Section 31-44-4 or40
a licensed group model health maintenance organization with an exclusive medical group41
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contract and which operates its own pharmacies which are licensed under Code42
Section 26-4-110.43
(6) 'State health plan' means:44
(A) The state employees' health insurance plan established pursuant to this article;45
(B) The health insurance plan for public school teachers and the health insurance plan46
for public school employees established pursuant to Subparts 2 and 3, respectively, of47
Part 6 of Article 17 of Chapter 2 of Title 20; and48
(C) The health benefit plan established for members, employees, and retirees of the49
Board of Regents of the University System of Georgia pursuant to Code Section 31-2-4.50
(b) On and after January 1, 2026, an insurer shall reimburse a pharmacy for a drug51
dispensed to a covered person for self-administration in the state health plan in an amount52
equal to:53
(1) The national average drug acquisition cost on the day of claim administration or, if54
unavailable, the rate provided in the Georgia estimated acquisition cost and select55
specialty pharmacy rates on the day of claim administration or, if unavailable, the56
wholesale acquisition cost on the day of claim administration; and57
(2) A professional dispensing fee that is not less than the professional dispensing fee paid58
by the state under Title XIX of the Social Security Act.59
(c) An insurer shall calculate a beneficiary's cost share or deductible based solely on the60
ingredient cost of a prescription drug and shall be prohibited from passing along the cost61
of the professional dispensing fee to a beneficiary through a cost share, deductible, or any62
other out-of-pocket payment by the beneficiary.63
(d) An insurer shall not circumvent the requirements regarding pharmacy reimbursement64
in this Code section in any manner, including without limitation by adjudicating claims65
through a prescription drug discount card or program.66
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(e) In addition to any other remedy provided by law, a violation of this Code section by67
an insurer shall give rise to a private right of action for damages and equitable remedies for68
the pharmacy or beneficiary aggrieved."69
SECTION 2.70
All laws and parts of laws in conflict with this Act are repealed.71
H. B. 196 (SUB)
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