HB810: HB810 Insurance; require that final reimbursements to pharmacies for prescription drugs are based on certain formulas

Pharmacy benefits managers (PBMs) are companies that process prescription drug claims for insurers and set how much pharmacies get paid. This bill adds a new section to Georgia's law on PBMs (O.C.G.A. Chapter 64 of Title 33) that sets a required reimbursement formula for what it calls 'eligible pharmacies,' meaning pharmacies not owned by anyone who owns an interest in more than ten pharmacies. Under the bill, a PBM must pay these pharmacies the national average drug acquisition cost for the drug, plus a professional dispensing fee matching Georgia's Medicaid dispensing fee. If that national cost figure is unavailable, the PBM would use the wholesale acquisition cost instead, plus the same dispensing fee. PBMs could not use 'effective rate guarantees' to average out these payments over time. The rule would not apply to the State Health Benefit Plan or Georgia Medicaid, and PBMs could still pay rural pharmacies more than the formula requires, except for affiliate, mail-order, and specialty pharmacies. The law would take effect July 1, 2027.

• Adds a new Code section requiring pharmacy benefits managers to pay eligible pharmacies based on the national average drug acquisition cost plus a set dispensing fee.
• Defines 'eligible pharmacy' as one not owned by a person or entity with ownership interests in more than ten pharmacies, excluding large chains and PBM-affiliated pharmacies from the formula's protections.
• Provides a backup pricing method (wholesale acquisition cost) if the national average drug acquisition cost is not available at the time of dispensing.
• Bars pharmacy benefits managers from using 'effective rate guarantees' to average out these required reimbursements over time.
• Exempts the State Health Benefit Plan and Georgia Medicaid, including Medicaid managed care, from the new reimbursement rule.
• Allows, but does not require, pharmacy benefits managers to pay rural pharmacies more than the formula requires, with exceptions for affiliate, mail-order, and specialty pharmacies.

Independent and small-chain pharmacies in Georgia that qualify as 'eligible pharmacies,' pharmacy benefits managers that process prescription claims for insurers, rural pharmacies specifically named for extra flexibility, and the Department of Community Health, which sets the dispensing fee used in the formula.

If enacted, many Georgia pharmacies would be guaranteed a reimbursement tied to actual drug acquisition costs plus a fixed dispensing fee, rather than rates set solely by pharmacy benefits managers. This could affect pharmacy finances and, in turn, drug availability, though the rule does not apply to Medicaid or the state employee health plan.

• Section 1 adds new Code Section 33-64-9.2, defining 'affiliate pharmacy,' 'eligible pharmacy,' 'rural area' (counties under 50,000 people per the 2020 census), and 'rural pharmacy.'
• Subsection (b) requires reimbursement equal to the national average drug acquisition cost plus a professional dispensing fee matching Georgia's Medicaid rate, with wholesale acquisition cost as a fallback.
• Subsection (b) also bans use of 'effective rate guarantees,' contractual terms letting PBMs average reimbursements to a predetermined rate over time.
• Subsection (c) exempts the State Health Benefit Plan (O.C.G.A. § 45-18-22) and Georgia Medicaid, including managed care organizations, from the new rule.
• Subsection (d) permits, but does not require, higher reimbursement for rural pharmacies, excluding affiliate, mail-order, and specialty pharmacies from that flexibility.
• Section 2 sets the effective date as July 1, 2027.

1. 2026-03-06House Committee Favorably Reported By Substitute (House)
2. 2026-03-03House Withdrawn, Recommitted (House)
3. 2026-02-19House Committee Favorably Reported By Substitute (House)
4. 2026-02-18House Withdrawn, Recommitted (House)
5. 2026-02-10House Committee Favorably Reported By Substitute (House)
6. 2025-03-25House Second Readers (House)
7. 2025-03-21House First Readers (House)
8. 2025-03-20House Hopper (House)

• Rick Jasperse (R, HD-011)Primary sponsor
• Lee Hawkins (R, HD-027)
• Darlene Taylor (R, HD-173)
• Ron Stephens (R, HD-164)
• Mark Newton (R, HD-127)
• Michelle Au (D, HD-050)

• pharmacy benefits managers
• prescription drug pricing
• independent pharmacies
• rural health care
• insurance regulation