Georgia CommonsHB196: HB196 State employees' health insurance plan; drugs dispensed for self-administration; provisions
Last action May 14, 2025 · Effective Date 2025-07-01
House Bill 196 requires state health plans in Georgia, including plans covering state employees, teachers, school staff, and University System employees, to reimburse pharmacies for self-administered drugs using a transparent, index-based pricing formula plus a set dispensing fee.
In plain language
Currently, how pharmacy benefits managers (companies that process prescription drug claims) reimburse pharmacies for drugs under Georgia's state health plans is not tied to a specific transparent pricing method. This bill adds a new section to Georgia law (O.C.G.A. § 45-18-22) that changes that starting January 1, 2026. Under the bill, insurers, including pharmacy benefits managers, must pay pharmacies based on the national average drug acquisition cost (a federal survey of what pharmacies actually pay for drugs) or, if that is not available, a discounted average wholesale price. On top of that, insurers must pay a dispensing fee of at least $10.50 for chain pharmacies and $11.50 for independent pharmacies. Insurers cannot get around these rules by routing claims through prescription discount cards or similar programs. The bill also gives the Commissioner of Insurance authority to enforce these requirements, in addition to whatever oversight state health plans already have under their contracts.
What the bill does
- Requires insurers to reimburse pharmacies for self-administered drugs under state health plans using the national average drug acquisition cost or a comparable wholesale price benchmark, starting January 1, 2026.
- Sets a minimum professional dispensing fee of $10.50 for chain pharmacies and $11.50 for independent pharmacies on top of the drug cost reimbursement.
- Bans insurers from avoiding these reimbursement rules by processing claims through prescription discount cards or similar workaround programs.
- Gives the Commissioner of Insurance enforcement authority over these pharmacy reimbursement rules, in addition to existing state health plan oversight.
- Defines key terms such as 'insurer,' 'pharmacy benefits manager,' 'independent pharmacy,' and 'state health plan' to clarify who the new rules apply to.
Who it affects
The bill affects insurers and pharmacy benefits managers handling Georgia's state health plans, chain and independent pharmacies that dispense drugs to covered members, and the state employees, public school teachers and staff, and University System of Georgia employees and retirees covered by those plans.
Why it matters
Pharmacies serving state health plan members would receive a guaranteed, transparent reimbursement formula and a minimum dispensing fee rather than rates set solely by pharmacy benefits managers, which could affect pharmacy finances, especially for independent pharmacies, and how drug costs are calculated within state health plans.
Key provisions
- Section 1 adds new Code Section 45-18-22, defining terms including 'insurer,' 'independent pharmacy,' 'national average drug acquisition cost,' 'pharmacy,' and 'pharmacy benefits manager.'
- Subsection (a)(6) defines 'state health plan' to include the state employees' plan, the teacher and school employee health plans, and the Board of Regents' health benefit plan.
- Subsection (b)(1) requires, effective January 1, 2026, reimbursement based on the national average drug acquisition cost or a discounted average wholesale/acquisition price, plus a dispensing fee of at least $10.50 (chain) or $11.50 (independent pharmacies).
- Subsection (b)(2) allows state health plans to authorize higher, but not lower, reimbursement than the required minimum.
- Subsection (c) prohibits insurers from circumventing the reimbursement rules, including through prescription discount cards or programs.
- Subsection (d) grants the Commissioner of Insurance enforcement authority under Chapter 64 of Title 33, governing pharmacy benefits managers, in addition to existing state health plan authority.
- Section 2 repeals any conflicting laws.
From the bill
“A professional dispensing fee that is not less than $10.50 for chain pharmacies and60 $11.50 for independent pharmacies.”
“An insurer shall not circumvent the requirements regarding pharmacy reimbursement65 in this Code section in any manner, including without limitatio n by adjudicating claims66 through a prescription drug discount card or program.”
Status timeline
- Effective Date 2025-07-01
- Act 307
- House Date Signed by Governor (House)
- House Sent to Governor (House)
- House Agreed Senate Amend or Sub (House)
- Senate Passed/Adopted By Substitute (Senate)
- Senate Third Read (Senate)
- Senate Read Second Time (Senate)
Show full history (16 actions)
- Senate Committee Favorably Reported By Substitute (Senate)
- Senate Read and Referred (Senate)
- House Passed/Adopted By Substitute (House)
- House Third Readers (House)
- House Committee Favorably Reported By Substitute (House)
- House Second Readers (House)
- House First Readers (House)
- House Hopper (House)
Sponsors
- Trey Kelley (R, HD-016)
- Darlene Taylor (R, HD-173)
- James Hatchett (R, HD-155)
- Carolyn Hugley (D, HD-141)
- Rick Jasperse (R, HD-011)
- Matthew Gambill (R, HD-015)
- Matt Brass (R, SD-006)
Votes
- House voteFebruary 21, 2025
168 yea, 0 nay (4 not voting, 8 absent)
- Senate voteMarch 27, 2025
55 yea, 0 nay (1 not voting, 0 absent)
- House voteMarch 31, 2025
166 yea, 0 nay (5 not voting, 9 absent)
Topics
- prescription drug pricing
- state employee health insurance
- pharmacy reimbursement
- health insurance regulation
- pharmacy benefits managers