25 LC 52 0858
House Bill 931
By: Representatives Lupton of the 83
rd
and Lim of the 98
th
A BILL TO BE ENTITLED
AN ACT
To amend Title 31 of the Official Code of Georgia Annotated, relating to health, so as to
1
establish a framework to control the high costs of prescription drugs in this state; to provide2
for definitions; to establish the Prescription Drug Affordability Board; to provide for such3
board's membership, powers, duties, and meetings; to provide for assessments; to authorize4
the board to identify certain prescription drugs for affordability review; to provide for certain5
health benefit plans to submit information to the board; to authorize the board to conduct an6
affordability review of certain prescription drugs; to authorize the board to establish an upper7
payment limit on certain prescription drugs; to provide for rights of aggrieved persons; to8
provide for the use of savings; to provide for notice requirements for a manufacturer to9
withdraw a drug from this state; to provide for penalties; to provide for annual reports; to10
provide for rules and regulations; to provide for programs receiving certain funds to negotiate11
specialist rates; to provide for related matters; to provide for legislative findings; to provide12
for an effective date; to repeal conflicting laws; and for other purposes.13
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:14
SECTION 1.15
(a) The purpose of this Act is to protect the safety, health, and economic well-being of16
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Georgians by taking steps to increase access to affordable prescription drugs. In enacting
17
this Act, the legislature finds that:18
(1) Access to prescription drugs is necessary for Georgians to maintain or acquire good19
health;20
(2) Excessive costs negatively impact the ability of Georgians to obtain prescription21
drugs, and costs that exceed reasonable levels endanger the health and safety of22
Georgians and their ability to maintain or achieve good health;23
(3) Lack of affordability of prescription drugs threatens the economic well-being of24
Georgians and endangers their ability to afford other necessary and essential goods and25
services, including housing, food, and utilities;26
(4) Excessive costs for prescription drugs contribute significantly to healthcare and27
health insurance costs and threaten the overall ability of Georgians to obtain healthcare28
coverage and maintain or achieve good health;29
(5) The high cost of prescription drugs contributes significantly to rising costs to the state30
for healthcare provided and paid for through health insurance programs for public31
employees, including employees of the state, municipalities and counties, school districts,32
institutions of higher education, and retirees whose healthcare costs are funded by public33
programs, thereby threatening the ability of the state to fund those programs adequately34
and further threatening the ability of the state to fund other programs necessary for the35
public good, such as public education and public safety; and36
(6) The costs to consumers, health benefit plans, and the state for prescription drug37
coverage is higher than the costs in other countries because the prices charged by38
manufacturers and distributors of drugs in Georgia are higher.39
(b) Based on these findings, the legislature finds that high costs of prescription drugs40
threaten the safety and well-being of Georgians and finds it is necessary to act in order to41
protect Georgians from the negative impact of excessive costs for prescription drugs.42
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SECTION 2.
43
Title 31 of the Official Code of Georgia Annotated, relating to health, is amended in Chapter44
2, relating to Department of Community Health, by designating Code Sections 31-2-145
through 31-2-19 as Article 1.46
SECTION 3.47
Said title is further amended in said chapter by adding a new article to read as follows:48
"ARTICLE 2
49
31-2-30.50
As used in this article, the term:51
(1) 'Affordability challenge' means a determination by the board that the costs of52
appropriate utilization of a prescription drug:53
(A) Exceed the therapeutic benefit of such drug; or54
(B) Are not sustainable to consumers or to public or private healthcare systems.55
(2) 'Biological product' means a virus, therapeutic serum, toxin, antitoxin, vaccine,56
blood, blood component or derivative, allergenic product, protein, or analogous product,57
or arsphenamine or derivative of arsphenamine or any other trivalent organic arsenic58
compound, applicable to the prevention, treatment, or cure of a disease or condition of59
human beings.60
(3) 'Biosimilar product' means a biological product highly similar to a reference61
biological product with no clinically meaningful differences in terms of the safety, purity,62
and potency of the product and with minor differences in clinically inactive components.63
(4) 'Board' means the Prescription Drug Affordability Board established under Code64
Section 31-2-31.65
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(5) 'ERISA plan' means a plan qualified under the federal Employee Retirement Income66
Security Act of 1974, 29 U.S.C. Section 1001, et seq.67
(6) 'Health benefit plan' means any hospital, health, or medical insurance policy; hospital68
or medical service contract; employee welfare benefit plan; contract or agreement with69
a health maintenance organization; subscriber contract or agreement; contract or70
agreement with a preferred provider organization; accident and sickness insurance benefit71
plan; or other insurance contract under any other name. Such term shall include any72
health insurance or benefit plan established pursuant to Part 6 of Article 17 of Chapter73
2 of Title 20, Code Section 31-2-4, Article 1 of Chapter 18 of Title 45, and Article 7 of74
Chapter 4 of Title 49, the 'Georgia Medical Assistance Act of 1977.'75
(7) 'Manufacturer' means an entity that engages in the manufacture, marketing, or76
distribution of a prescription drug or enters into an agreement with another manufacturer77
to manufacture, market, or distribute a prescription drug under such entity's name and sets78
or changes the wholesale acquisition cost of the prescription drug it manufactures,79
markets, or distributes.80
(8) 'Participating ERISA plan' means an ERISA plan that has elected to participate in the81
requirements and restrictions as provided in Code Section 31-2-35.82
(9) 'Pharmacy benefits manager' shall have the same meaning as set forth in Code83
Section 33-64-1.84
(10) 'Pharmacy wholesale distributor' means any person engaged in the wholesale85
distribution of prescription drugs, including, but not limited to, manufacturers; repackers;86
own label distributors; private-label distributors; jobbers; brokers; warehouses, including87
manufacturers' and distributors' warehouses, chain drug warehouses, and wholesale drug88
warehouses; independent wholesale drug traders; and retail pharmacies that conduct89
wholesale distributions.90
(11) 'Prescription drug' shall have the same meaning as set forth in Code Section91
26-4-201. Such term shall include any biological product or biosimilar product.92
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(12) 'State entity' means any agency of state government that purchases prescription93
drugs on behalf of the state for a person whose healthcare is paid for by the state,94
including any agent, vendor, fiscal agent, contractor, or other party acting on behalf of95
the state.96
(13) 'Wholesale acquisition cost' has the same meaning as set forth in 42 U.S.C. Section97
1395w-3a(c)(6)(B).98
31-2-31.99
(a) There is hereby established the Prescription Drug Affordability Board for the purpose100
of protecting residents of this state, state and local governments, health benefit plans,101
healthcare providers, pharmacies, and other stakeholders within the healthcare system in102
this state from the high costs of prescription drugs.103
(b)(1) The board shall consist of five members appointed by the Governor and confirmed104
by the Senate. The Governor shall designate the initial terms of the members of the board105
as follows: one member shall be appointed for one year, two members shall be appointed106
for two years, and two members shall be appointed for three years. Thereafter, all107
members shall serve for terms of four years and until their successors are appointed and108
qualified.109
(2) When a vacancy occurs for any reason other than expiration of term, the Governor110
shall make an appointment to become immediately effective for the remainder of the111
unexpired term. Any appointment made by the Governor when the Senate is not in112
session shall be effective until the appointment is acted upon by the Senate.113
(c) A board member shall:114
(1) Be a resident of this state;115
(2) Have an advanced degree, experience, or expertise in healthcare policy, healthcare116
economics, or clinical medicine; and117
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(3) Not be an employee or board member of or consultant to a manufacturer, pharmacy118
benefits manager, health benefit plan, pharmacy wholesale distributor, or related trade119
association.120
(d)(1) The board shall elect a chairperson and a vice chairperson from among its121
members, each to serve for a term of one year commencing on the first day of July each122
year.123
(2) The board shall have the authority to hire an executive director and staff necessary124
to conduct the board's activity as provided in this article.125
(e) The commissioner or his or her designee shall serve as an ex officio member of the126
board, and the department shall provide staff support and may employ consultants,127
investigators, or other staff as necessary for the board to carry out its duties.128
(f) The board shall assess and collect an annual assessment on manufacturers, health129
benefit plans, pharmacy benefits managers, and pharmacy wholesale distributors that sell130
or offer for sale any prescription drugs to persons in this state. The board shall specify the131
methodology for determining the amount of such assessment and the methodology and132
timeline for collecting such assessment pursuant to rules and regulations promulgated and133
adopted by the board.134
(g) The board shall have the authority to enter into a contract with a third party for any135
service necessary to carry out the powers and duties of the board.136
(h) The board may seek, accept, and expend gifts, grants, and donations from private or137
pubic sources for the purposes of this article; provided, however, that the board shall not138
accept any gift, grant, or donation that creates a conflict of interest or the appearance of any139
conflict of interest for any board member.140
(i) Board members, department employees, and contractors providing services to or on141
behalf of the board shall recuse themselves from any board activity in which they have a142
conflict of interest. As used in this subsection, the term 'conflict of interest' means an143
association, including a financial or personal association, that has the potential to bias or144
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appear to bias an individual's decisions in matters related to the board or the activities of145
the board.146
(j) The board may establish advisory groups consisting of relevant stakeholders.147
(k) The board has the authority to promulgate and adopt rules and regulations to allow it148
to carry out its duties and powers under this article.149
(l) A simple majority of the board's membership shall constitute a quorum for the purpose150
of conducting business. Decisions of the board shall be determined by majority vote of151
board members present.152
(m) All meetings of the board shall be open to the public in accordance with Chapter 14153
of Title 50, relating to open and public meetings, and all public records shall be subject to154
disclosure in accordance with Article 4 of Chapter 18 of Title 50, relating to open records;155
provided, however, that the board may hold executive sessions to discuss trade secrets or156
proprietary information, and such information shall be confidential by law and privileged;157
shall not be subject to disclosure under the provisions of Article 4 of Chapter 18 of Title158
50, relating to open records; shall not be subject to subpoena; and shall not be subject to159
discovery or admissible in evidence in any private civil action.160
(n) The board shall meet at least quarterly at a time and place determined by the161
chairperson. The board may also meet at other times and places specified by the call of the162
chairperson or a majority of the board members.163
(o) Each board member shall receive the daily expense allowance and travel164
reimbursement as provided in Code Section 45-7-21 for actual attendance at board165
meetings in this state.166
31-2-32.167
(a) The board shall select prescription drugs for affordability review from the categories168
of prescription drugs identified pursuant to subsection (b) of this Code section.169
(b) Beginning January 1, 2026, and annually thereafter, the board shall identify:170
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(1) Prescription drugs that, as adjusted annually by the increase or decrease in the cost171
of living for the previous calendar year, have:172
(A) A wholesale acquisition cost of $3,000.00 or more per year; or173
(B) A wholesale acquisition cost increase of $300.00 or more in the preceding 12174
month period; or175
(B) A wholesale acquisition cost increase of 200 percent or more in the preceding 12176
months;177
(2) Biosimilar products with an initial wholesale acquisition cost that is not at least 15178
percent below the wholesale acquisition cost of the reference biological product at the179
time the biosimilar product is launched;180
(3) Prescription drugs referred to the board as possessing potential affordability181
challenges;182
(4) Prescription drugs referred to the board by any advisory group created by the board;183
and184
(5) The following information on categories of prescription drugs and premiums, based185
on reports submitted annually from each health benefit plan:186
(A) The 50 prescription drugs that are most frequently dispensed by pharmacies for187
claims covered under such plan and the total number of paid claims for each such drug;188
(B) The 50 prescription drugs that are most costly with respect to such plan based on189
total annual spending and the annual amount paid for each such drug after any rebates190
or other price concessions;191
(C) The 50 prescription drugs with the greatest increase in expenditures under such192
plan during the year preceding the year of the report, and, for each such drug, the193
change in the amount expended under such plan in each year after any rebates or other194
price concessions;195
(D) The 50 prescription drugs that are most costly based on average out-of-pocket cost196
per insured, member, or covered person under such plan;197
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(E) Any impact on premiums of such plan from rebates, fees, and other remuneration198
paid by manufacturers to such plan or its administrators or service providers with199
respect to prescription drugs prescribed to insureds, members, or covered persons under200
such plan, including, but not limited to:201
(i) The amounts paid by manufacturers for each therapeutic class of drugs; and202
(ii) The amounts by paid manufacturers for each of the 25 drugs that yielded the203
highest amount of rebates and other remuneration under such plan during the prior204
year; and205
(F) Any reduction in premiums and out-of-pocket costs to insureds, members, or206
covered persons under the plan.207
(c) The reports submitted to the board by each health benefit plan as provided for in208
paragraph (5) of subsection (b) of this Code section shall include the following information209
for each prescription drug:210
(1) Total annual spending by the plan after any rebates and other price concessions;211
(2) Total annual spending by insureds, members, or covered persons under the plan;212
(3) The number of insureds, members, or covered persons with a paid prescription drug213
claim;214
(4) Total dosage units dispensed; and215
(5) The number of paid claims.216
31-2-33.217
(a) In performing an affordability review of a prescription drug, the board shall be218
authorized to consider any documents and information relating to the manufacturer's219
selection of the introductory price or any price increase of such drug, including documents220
and information relating to:221
(1) Life cycle management;222
(2) The average cost of such drug;223
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(3) Market competition and context;224
(4) Projected revenue;225
(5) The estimated cost-effectiveness of the drug;226
(6) Off-label usage of the drug;227
(7) Development and manufacturing costs; and228
(8) Any consumer assistance programs funded by the manufacturer.229
(b) To the extent practicable, the board shall access pricing information for prescription230
drugs by:231
(1) Accessing available information from the all-payer claims database in this state and232
other states;233
(2) Entering into an interagency agreement with any state entity to share information234
collected by such entity;235
(3) Entering into a memorandum of understanding with another state to which236
manufacturers already report pricing information; and237
(4) Accessing other publicly available pricing information.238
31-2-34.239
(a) The board shall be authorized to conduct an affordability review of any prescription240
drug identified pursuant to Code Section 31-2-32 to determine whether the cost of such241
drug poses an affordability challenge.242
(b) When conducting an affordability review for a prescription drug, the board shall be243
authorized to consider any of the following criteria:244
(1) The relevant factors contributing to the price paid for the drug, including the245
wholesale acquisition cost, discounts, rebates, or other price concessions;246
(2) The average patient co-pay or other cost-sharing for the drug;247
(3) The effect of the price on consumers' access to the drug in this state;248
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(4) Whether the cost of the drug contributes to inequities in the availability of healthcare249
to underserved communities in this state;250
(5) The dollar value and accessibility of patient assistance programs offered by the251
manufacturer for the drug;252
(6) The price and availability of therapeutic alternatives;253
(7) Input from any advisory groups established by the board;254
(8) Input from patients affected by the condition or disease treated by the drug and255
individuals with medical or scientific expertise related to the condition or disease treated256
by the drug;257
(9) Life cycle management;258
(10) The average cost of the drug in this state;259
(11) Market competition and context;260
(12) Projected manufacturer revenue, if available;261
(13) Off-label usage of the drug; and262
(14) Any other relevant factors as determined by the board.263
(c) Prior to conducting an affordability review under this Code section, the board shall264
publish which prescription drugs are subject to such review and shall notify the265
manufacturer of any prescription drug subject to review.266
(d) At the conclusion of an affordability review under this Code section, the board shall267
determine whether the cost of a reviewed prescription drug presents an affordability268
challenge necessitating the establishment of an upper payment limit as provided for in269
Code Section 33-2-35.270
31-2-35.271
(a) Prior to setting any upper payment limits, the board shall establish by rule a272
methodology for setting upper payment limits.273
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(b) The board may set an upper payment limit for each prescription drug for which it274
determines there is an affordability challenge.275
(c) The methodology used by the board to set an upper payment limit may take into276
consideration:277
(1) The cost of administering the prescription drug;278
(2) The cost of delivering the prescription drug to patients;279
(3) The status of the prescription drug on the drug shortage list published by the United280
States Food and Drug Administration;281
(4) The difference between the price of the drug in this state and other states and between282
the price in the United States and in other countries;283
(5) Other relevant administrative costs related to the production and delivery of the284
prescription drug; and285
(6) Other relevant criteria the board, accounting for any stakeholder input, determines286
is necessary.287
(d) The methodology determined by the board shall consider whether an upper payment288
limit may help alleviate health disparities and inequitable outcomes for underserved289
communities, people with disabilities, older adults, or any other socially, economically, or290
environmentally disadvantaged group.291
(e) The board shall not employ a measure or metric which assigns a reduced value to the292
life extension provided by a prescription drug based on a pre-existing disability or chronic293
health condition of the individuals whom the prescription drug would benefit.294
(f) The board shall be authorized to suspend an upper payment limit if it determines that295
there is a shortage of the drug in this state, unless the board determines that such shortage296
was caused by a manufacturer or its agent.297
(g) An upper payment limit for a prescription drug established by the board applies to all298
purchases of the prescription drug and reimbursements for a claim for the drug when such299
drug is dispensed or administered to an individual in this state in person, by mail, or by300
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other means. An upper payment limit does not include a pharmacy dispensing fee, and301
nothing in this article shall be interpreted to prevent a retail pharmacy from receiving a302
payment that includes a dispensing fee above the upper payment limit.303
(h) An ERISA plan may elect to be subject to the upper payment limits established by the304
board.305
(i) The board shall publish a list of prescription drugs for which it has set an upper306
payment limit.307
(j) Unless the board prescribes a specific effective date, upper payment limits established308
by the board shall become effective six months after the adoption of the upper payment309
limit and apply only to purchases, contracts, and plans that are issued on or renewed after310
the effective date.311
(k) The establishment of an upper payment limit shall constitute final agency action. Any312
person or entity may request a contested case hearing, in accordance with the procedures313
established for such hearings by Chapter 13 of Title 50, the 'Georgia Administrative314
Procedure Act,' no later than 30 days after the decision is issued. The board shall consider315
the appeal and issue a final decision concerning the appeal within 60 days after the board316
receives the appeal. Final decisions as a result of such appeals are subject to judicial317
review.318
31-2-36.319
Any savings generated by a health benefit plan, state entity, or participating ERISA plan320
that are attributable to the implementation of an upper payment limit established by the321
board shall be used to reduce costs to consumers, prioritizing the reduction of out-of-pocket322
costs for prescription drugs. No later than April 1 of each calendar year, each health323
benefit plan, state entity, and participating ERISA plan shall submit to the board, the324
commissioner, and the Commissioner of Insurance a report describing the savings achieved325
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as a result of implementing upper payment limits and how those savings were used to326
reduce costs to consumers.327
31-2-37.328
(a) Any manufacturer that intends to withdraw from sale or distribution within this state329
a prescription drug for which the board has established an upper payment limit shall330
provide a notice of withdrawal in writing at least six months before the withdrawal to the331
board, the commissioner, the Commissioner of Insurance, the Attorney General, and any332
state entity with which the manufacturer has a contract for the sale or distribution of the333
drug.334
(b) The board shall assess a penalty not to exceed $500,000.00 if the board determines that335
a manufacturer failed to provide the notice required by subsection (a) of this Code section336
before withdrawing from sale or distribution within this state any prescription drug for337
which the board has established an upper payment limit.338
31-2-38.339
All assessments, penalties, and donations and grants received by the board and any interest340
earned on such shall be paid over into the general fund of the state treasury in accordance341
with Code Section 45-12-92.342
31-2-39.343
No later than December 1, 2026, and annually thereafter, the board shall submit a report344
to the commissioner, the Commissioner of Insurance, the Office of Health Strategy and345
Coordination, and the chairpersons of the House Committee on Health, the House346
Committee on Insurance, the House Committee on Public and Community Health, the347
Senate Health and Human Services Committee, and the Senate Insurance and Labor348
Committee. Such report shall include the following information:349
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(1) Publicly available data concerning price trends for prescription drugs;350
(2) A list of the prescription drugs that were subjected to an affordability review by the351
board, including the results of such affordability review;352
(3) A list of each prescription drug for which the board established an upper payment353
limit, including the amount of the upper payment limit;354
(4) With respect to each prescription drug for which the board conducted an affordability355
review, how the board determined whether the cost of such drug contributes to health356
disparities and inequitable outcomes for underserved communities, people with357
disabilities, older adults, or any other socially, economically, or environmentally358
disadvantaged group;359
(5) With respect to each drug for which the board set an upper payment limit, how the360
board assessed health disparities and inequitable outcomes for underserved communities,361
people with disabilities, older adults, or any other socially, economically, or362
environmentally disadvantaged group;363
(6) The known impact of any upper payment limits established by the board on364
healthcare providers and pharmacies and the ability of Georgians to access such drugs;365
(7) A summary of any appeals of decisions by the board and the outcome of any such366
appeal;367
(8) A description of each conflict of interest that was disclosed to the board during the368
preceding year;369
(9) A description of any violations of any of the provisions of this article, including an370
indication of any enforcement action taken in response to any such violation; and371
(10) Any recommendations the board may have for legislative and regulatory changes372
to increase the affordability of prescription drugs and reduce the effects of costs on373
consumers and the healthcare systems in this state.374
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31-2-40.375
The board shall promulgate rules and regulations necessary to implement the provisions376
of this article."377
SECTION 4.378
Said title is further amended in Chapter 8, relating to care and protection of indigent and379
elderly patients, by revising Code Section 31-8-154, relating to authorized expenditure of380
contributed funds, as follows:381
"31-8-154.382
All moneys contributed and revenues deposited and transferred to the trust fund pursuant383
to this article and any interest earned on such moneys shall be appropriated to the384
department for only the following purposes:385
(1) To expand Medicaid eligibility and services;386
(2) For programs to support rural and other health care healthcare providers, primarily387
hospitals, who serve the medically indigent, provided that such programs shall negotiate388
specialist care rates with primary healthcare programs described in paragraph (3) of this389
Code section;390
(3) For primary health care healthcare programs for medically indigent citizens and391
children of this state; or392
(4) Any combination of purposes specified in paragraphs (1) through (3) of this Code393
section."394
SECTION 5.395
This Act shall become effective upon its approval by the Governor or upon its becoming law396
without such approval.397
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SECTION 6.
398
All laws and parts of laws in conflict with this Act are repealed.399
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