HB 810: Insurance; require that final reimbursements to pharmacies for prescription drugs are based on certain formulas

Pharmacy benefits managers (companies that process prescription drug claims for insurers) currently negotiate reimbursement rates with pharmacies, and critics say those rates can be unpredictable or squeeze independent drugstores. HB810 adds a new section to Georgia's pharmacy benefits manager law setting a required formula for what counts as 'eligible pharmacies,' generally those not owned by a company with stakes in more than ten pharmacies. Under the bill, a pharmacy benefits manager must pay an eligible pharmacy the national average drug acquisition cost for a drug, plus a dispensing fee matching the current Georgia Medicaid rate. If that national cost figure is unavailable, the manager must use the wholesale acquisition cost as of January 1, 2026, plus the same dispensing fee. The law would not apply to the State Health Benefit Plan or to Medicaid programs. Pharmacies in rural counties (under 50,000 people) could still be paid more than the formula amount, except for affiliate, mail-order, or specialty pharmacies. The law would take effect July 1, 2027.

• Creates a new Georgia law (O.C.G.A. Section 33-64-9.2) setting a mandatory reimbursement formula pharmacy benefits managers must use for eligible pharmacies.
• Defines 'eligible pharmacy' to exclude pharmacies owned by entities with stakes in more than ten pharmacies, and defines 'affiliate pharmacy' as one connected to a pharmacy benefits manager.
• Requires reimbursement equal to the national average drug acquisition cost plus a dispensing fee matching Georgia's Medicaid dispensing fee rate.
• Bars pharmacy benefits managers from folding these required payments into 'effective rate guarantees' that average reimbursements over time.
• Exempts the State Health Benefit Plan and Medicaid programs from the new reimbursement rules.
• Allows higher payments to rural pharmacies but excludes affiliate, mail-order, and specialty pharmacies from that rural exception.

Independent and small-chain pharmacies across Georgia, especially those in rural counties with fewer than 50,000 residents, as well as pharmacy benefits managers that process prescription drug claims for private insurance plans. State Medicaid programs and the State Health Benefit Plan are explicitly excluded.

Eligible pharmacies would gain a guaranteed minimum payment formula rather than relying on negotiated or fluctuating rates set by pharmacy benefits managers, which could affect their financial stability. Rural pharmacies could still negotiate higher payments, potentially helping keep drugstores open in smaller communities.

• Section 1 adds new Code Section 33-64-9.2 defining 'eligible pharmacy,' 'affiliate pharmacy,' 'rural area,' and 'rural pharmacy' for purposes of the reimbursement rule.
• Subsection (b) sets the reimbursement formula: national average drug acquisition cost plus a Georgia Medicaid-matching dispensing fee, with a fallback to wholesale acquisition cost as of January 1, 2026 if the national figure is unavailable.
• Subsection (b) also bars pharmacy benefits managers from applying 'effective rate guarantees' that average out reimbursements over time to these required payments.
• Subsection (c) exempts the State Health Benefit Plan and Medicaid, including Medicaid managed care organizations, from the new rule.
• Subsection (d) permits higher payments to rural pharmacies but excludes affiliate, mail-order, and specialty pharmacies from that exception.
• Section 2 sets the effective date as July 1, 2027.

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

• Rick Jasperse (R, HD-011)Patrocinador principal
• 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 reimbursement
• pharmacy benefits managers
• prescription drug costs
• rural pharmacies
• insurance regulation