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

26 LC 46 1507S The House Committee on Health offers the following substitute to HB 810: A BILL TO BE ENTITLED AN ACT To amend Chapter 64 of Title 33 of the Official Code of Georgia Annotated, relating to1 regulation and licensure of pharmacy benefits managers, so as t o require that final2 reimbursements to eligible pharmacies for prescription drugs are based on certain formulas;3 to provide for applicability; to provide for definitions; to provide for construction; to provide4 for related matters; to provide for an effective date and appli cability; to repeal conflicting5 laws; and for other purposes.6 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:7 SECTION 1.8 Chapter 64 of Title 33 of the Official Code of Georgia Annotated, relating to regulation and9 licensure of pharmacy benefits managers, is amended by adding a new Code section to read10 as follows:11 "33-64-9.2.12 (a) As used in this Code section:13 (1) 'Affiliate pharmacy' means a pharmacy which, either directly or indirectly through14 one or more intermediaries:15 H. B. 810 (SUB) - 1 - 26 LC 46 1507S (A) Has an investment or ownership interest in a pharmacy benefits manager licensed16 under this chapter;17 (B) Shares common ownership with a pharmacy benefits manager licensed under this18 chapter; or19 (C) Has an investor or ownership interest holder which is a pharmacy benefits manager20 licensed under this chapter.21 (2) 'Eligible pharmacy' means a pharmacy which is not owned by an entity or natural22 person that has an investor or ownership interests in more than ten pharmacies.23 (3) 'Rural area' means any county having a population of less than 50,000 according to24 the United States decennial census of 2020 or any future such census.25 (4) 'Rural pharmacy' means any eligible pharmacy located in a rural area.26 (b) A pharmacy benefits manager shall ensure that the final reimbursement, after taking27 into account any and all fees, charges, adjustments, or other reductions, including, but not28 limited to, direct or indirect renumeration fees, administrative fees, performance based fees,29 network access fees, or any other fees or adjustments, or other similar constructs, to an30 eligible pharmacy for a prescription drug is in an amount equal to the national average drug31 acquisition cost for the prescription drug at the time that such drug was dispensed, plus a32 professional dispensing fee in an amount equal to the current G eorgia Medicaid33 professional dispensing fee as determined by the Department of Community Health. If the34 national average drug acquisition cost at the time such drug was dispensed is not available,35 a pharmacy benefits manager shall reimburse an eligible pharmacy in an amount equal to36 the wholesale acquisition cost o f the drug, as defined in 42 U. S.C.37 Section 1395w-3a(c)(6)(B), on January 1, 2026, plus a professio nal dispensing fee in an38 amount equal to the current Georgia Medicaid professional dispensing fee as determined39 by the Department of Community Health. A pharmacy benefits manager shall exclude any40 reimbursement made pursuant to this subsection from any effecti ve rate guarantees. As41 used in this subsection, the term 'effective rate guarantees' means a contractual provision42 H. B. 810 (SUB) - 2 - 26 LC 46 1507S whereby a pharmacy benefits manager may adjust reimbursement ra tes to eligible43 pharmacies for prescription drugs dispensed by any such pharmacy during a certain period44 of time, ensuring that the pharmacy's overall reimbursement ave rages out to be a45 predetermined rate.46 (c) This Code section shall not apply to a state health plan, as such term is defined in Code47 Section 45-18-22. This Code section shall also not apply to Medicaid under Chapter 4 of48 Title 49, including Medicaid managed care programs administered through care49 management organizations.50 (d) Notwithstanding any other provision of this Code section, nothing herein shall be51 construed to prohibit or restrict a pharmacy benefits manager f rom providing52 reimbursement to a rural pharmacy in an amount exceeding the na tional average drug53 acquisition cost for a prescription drug plus the professional dispensing fee otherwise54 required under this Code section; provided, however, that this exception shall not apply to55 affiliate, mail-order, and specialty pharmacies."56 SECTION 2.57 This Act shall become effective July 1, 2027.58 SECTION 3.59 All laws and parts of laws in conflict with this Act are repealed.60 H. B. 810 (SUB) - 3 -