Georgia 2025-2026 Regular Session

Georgia House Bill HB196 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	25 HB 196/AP
2		-	House Bill 196 (AS PASSED HOUSE AND SENATE)
3		-	By: Representatives Kelley of the 16
4		-	th
5		-	, Taylor of the 173
6		-	rd
7		-	, Hatchett of the 155
8		-	th
9		-	, Hugley of
10		-	the 141
11		-	st
12		-	, Jasperse of the 11
13		-	th
14		-	, and others
	1	+	25 LC 57 0274S
	2	+	The Senate Committee on Insurance and Labor offered the following
	3	+	substitute to HB 196:
15	4		A BILL TO BE ENTITLED
16	5		AN ACT
17		-	To amend Part 1 of Article 1 of Chapter 18 of Title 45 of the Official Code of Georgia
18		-	1
	6	+	To amend Part 1 of Article 1 of Chapter 18 of Title 45 of the Official Code of Georgia1
19	7		Annotated, relating to state employees' health insurance plan, so as to require that drugs2
20	8		dispensed to a covered person for self-administration under a state health plan be reimbursed3
21	9		using a transparent, index based price, plus a dispensing fee; to provide for enforcement4
22	10		authority by the Commissioner of Insurance; to provide for definitions; to provide for related5
23	11		matters; to repeal conflicting laws; and for other purposes.6
24	12		BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:7
25	13		SECTION 1.8
26	14		Part 1 of Article 1 of Chapter 18 of Title 45 of the Official Code of Georgia Annotated,9
27	15		relating to state employees' health insurance plan, is amended by adding a new Code section10
28	16		to read as follows:11
29		-	"45-18-22.
30		-	12
	17	+	"45-18-22.12
31	18		(a) As used in this Code section, the term:13
32	19		(1) 'Independent pharmacy' means an entity contracted with the PBM pursuant to an14
33	20		agreement with a single retail pharmacy, or is contracted with the PBM through a15
34	21		pharmacy services administrative organization.16
35		-	H. B. 196
36		-	- 1 - 25 HB 196/AP
	22	+	- 1 - 25 LC 57 0274S
37	23		(2) 'Insurer' means a corporation licensed to transact accident and sickness or major17
38	24		medical insurance business in this state, a healthcare corporation, a health maintenance18
39	25		organization, a pharmacy benefits manager, or any other entity that provides healthcare19
40	26		coverage or services pursuant to a state health plan. Such term shall not include any20
41	27		licensed group model health maintenance organization with an exclusive medical group21
42	28		contract and which operates its own pharmacies which are licensed under Code22
43	29		Section 26-4-110.23
44	30		(3) 'National average drug acquisition cost' means the monthly survey of retail24
45	31		pharmacies conducted by the federal Centers for Medicare and Medicaid Services to25
46	32		determine average acquisition cost for Medicaid covered outpatient drugs.26
47	33		(4) 'Pharmacy' means a pharmacy or pharmacist licensed or holding a nonresident27
48	34		pharmacy permit pursuant to Chapter 4 of Title 26.28
49	35		(5) 'Pharmacy benefits manager' or 'PBM' means a person, business entity, or other entity29
50	36		that performs pharmacy benefits management as such term is defined in Chapter 64 of30
51	37		Title 33. The term 'pharmacy benefits manager' includes a person or entity acting for a31
52	38		pharmacy benefits manager in a contractual or employment relationship in the32
53	39		performance of pharmacy benefits management for a health plan, including operating or33
54	40		administering a prescription card or prescription discount program directly or on behalf34
55	41		of a pharmacy benefits manager or insurer for covered persons for drugs not covered or35
56	42		being reimbursed by the covered person's pharmacy benefits manager or health plan. 36
57	43		Such term shall not include services provided by pharmacies operating under a hospital37
58	44		pharmacy license. Such term shall not include health systems while providing pharmacy38
59	45		services for their patients, employees, or beneficiaries, for indigent care, or for the39
60	46		provision of drugs for outpatient procedures. Such term shall not include services40
61	47		provided by pharmacies affiliated with a facility licensed under Code Section 31-44-4 or41
62	48		a licensed group model health maintenance organization with an exclusive medical group42
63		-	H. B. 196
64		-	- 2 - 25 HB 196/AP
	49	+	- 2 - 25 LC 57 0274S
65	50		contract and which operates its own pharmacies which are licensed under Code43
66	51		Section 26-4-110.44
67	52		(6) 'State health plan' means:45
68	53		(A) The state employees' health insurance plan established pursuant to this article;46
69	54		(B) The health insurance plan for public school teachers and the health insurance plan47
70	55		for public school employees established pursuant to Subparts 2 and 3, respectively, of48
71	56		Part 6 of Article 17 of Chapter 2 of Title 20; and49
72	57		(C) The health benefit plan established for members, employees, and retirees of the50
73	58		Board of Regents of the University System of Georgia pursuant to Code Section 31-2-4.51
74	59		(b)(1) On and after January 1, 2026, an insurer shall reimburse a pharmacy for a drug52
75	60		dispensed to a covered person for self-administration in the state health plan in an amount53
76	61		equal to:54
77	62		(A) The national average drug acquisition cost on the day of claim administration or,55
78	63		if unavailable, a discounted percentage of the average wholesale price or wholesale 56
79	64		acquisition cost on the day of claim administration as determined by the state health57
80	65		plan based on current competitive market rates or, if unavailable, the wholesale58
81	66		acquisition cost; and59
82	67		(B) A professional dispensing fee that is not less than $10.50 for chain pharmacies and60
83	68		$11.50 for independent pharmacies.61
84	69		(2) Nothing in this subsection shall prohibit a state health plan from authorizing62
85	70		reimbursement by an insurer to a pharmacy for a drug or drugs in excess of but not lower63
86	71		than the amount required pursuant to paragraph (1) of this subsection.64
87	72		(c) An insurer shall not circumvent the requirements regarding pharmacy reimbursement65
88	73		in this Code section in any manner, including without limitation by adjudicating claims66
89	74		through a prescription drug discount card or program.67
90	75		(d) The Commissioner of Insurance shall have enforcement authority over this Code68
91	76		section and to take any other actions pursuant to any authority granted under Chapter 6469
92		-	H. B. 196
93		-	- 3 - 25 HB 196/AP
	77	+	- 3 - 25 LC 57 0274S
94	78		of Title 33, relating to the regulation and licensure of pharmacy benefits managers. Such70
95	79		authority shall be in addition to any authority granted to the applicable state health plan71
96	80		under contract or law."72
97	81		SECTION 2.73
98	82		All laws and parts of laws in conflict with this Act are repealed.74
99		-	H. B. 196
100	83		- 4 -