HB 196: State employees' health insurance plan; drugs dispensed for self-administration; provisions

Right now Georgia's state health plans (covering state employees, public school teachers and employees, and University System of Georgia members and retirees) reimburse pharmacies for prescription drugs through arrangements that can lack clear pricing standards. This bill adds a new section to Georgia law setting a specific reimbursement formula: pharmacies must be paid based on the national average drug acquisition cost, or if that's unavailable, a discounted percentage of average wholesale price or wholesale acquisition cost, plus a professional dispensing fee of at least $10.50 for chain pharmacies and $11.50 for independent pharmacies. The bill defines key terms like insurer, pharmacy benefits manager, and independent pharmacy, and bars insurers from getting around these reimbursement rules, including by routing claims through prescription discount cards. It gives the Commissioner of Insurance enforcement authority under Georgia's pharmacy benefits manager law (O.C.G.A. Chapter 33-64). The new reimbursement rules take effect January 1, 2026.

• Sets a minimum pharmacy reimbursement formula for drugs dispensed for self-administration under Georgia's state health plans, based on the national average drug acquisition cost or a comparable benchmark price.
• Requires a professional dispensing fee on top of the drug cost, at least $10.50 for chain pharmacies and $11.50 for independent pharmacies.
• Prohibits insurers and pharmacy benefits managers from bypassing these reimbursement rules, including through prescription discount card programs.
• Gives the Commissioner of Insurance enforcement authority over these pharmacy reimbursement rules under Georgia's pharmacy benefits manager law.
• Defines which health plans count as a 'state health plan' covered by the new rules: state employees, public school teachers and employees, and University System of Georgia members and retirees.
• Sets the new reimbursement requirement to take effect January 1, 2026.

State employees, public school teachers and employees, and University System of Georgia members and retirees who get prescriptions through their state health plans; pharmacies, especially independent and chain pharmacies that dispense those drugs; insurers and pharmacy benefits managers that administer the plans; and the Commissioner of Insurance, who gains enforcement duties.

Pharmacies serving state employees, teachers, and university system members would get a guaranteed, formula based payment plus a dispensing fee instead of reimbursement rates set solely by insurers or pharmacy benefits managers, which could affect independent pharmacies' finances and how state health plans budget for prescription drug costs.

• Section 1 adds new Code Section 45-18-22, defining terms including independent pharmacy, insurer, national average drug acquisition cost, pharmacy, pharmacy benefits manager, and state health plan.
• Subsection (b) sets the reimbursement formula: national average drug acquisition cost (or a fallback wholesale price benchmark) plus a dispensing fee of at least $10.50 (chain) or $11.50 (independent), effective January 1, 2026.
• Subsection (b)(2) allows state health plans to authorize higher reimbursement than the required minimum, but not lower.
• Subsection (c) bars insurers from circumventing the reimbursement rules, specifically naming prescription drug discount cards or programs as a prohibited workaround.
• Subsection (d) grants the Commissioner of Insurance enforcement authority under Georgia's pharmacy benefits manager licensing law (Chapter 64 of Title 33), in addition to any authority under existing contracts or law.
• Section 2 repeals any conflicting laws.

1. 2025-05-14Effective Date 2025-07-01
2. 2025-05-14Act 307
3. 2025-05-14House Date Signed by Governor (Cámara de Representantes)
4. 2025-04-07House Sent to Governor (Cámara de Representantes)
5. 2025-03-31House Agreed Senate Amend or Sub (Cámara de Representantes)
6. 2025-03-27Senate Passed/Adopted By Substitute (Senado)
7. 2025-03-27Senate Third Read (Senado)
8. 2025-03-21Senate Read Second Time (Senado)

• Trey Kelley (R, HD-016)Patrocinador principal
• 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)

1. AprobadaVotación: Cámara de Representantes21 de febrero de 2025

   168 a favor, 0 en contra (4 sin votar, 8 ausentes)

   Passage: House Vote #66

2. AprobadaVotación: Senado27 de marzo de 2025

   55 a favor, 0 en contra (1 sin votar, 0 ausentes)

   Passage By Substitute: Senate Vote #299

3. AprobadaVotación: Cámara de Representantes31 de marzo de 2025

   166 a favor, 0 en contra (5 sin votar, 9 ausentes)

   Agree To Senate Substitute: House Vote #355

• prescription drug pricing
• state employee health insurance
• pharmacy reimbursement
• pharmacy benefits managers
• teacher health plans