45-18-22. Requirements for insurers relating to pharmacy reimbursements; enforcement.

As used in this Code section, the term:#

1. (1)

   “Independent pharmacy” means an entity contracted with the PBM pursuant to an agreement with a single retail pharmacy, or is contracted with the PBM through a pharmacy services administrative organization.#

2. (2)

   “Insurer” means a corporation licensed to transact accident and sickness or major medical insurance business in this state, a healthcare corporation, a health maintenance organization, a pharmacy benefits manager, or any other entity that provides healthcare coverage or services pursuant to a state health plan. Such term shall not include any licensed group model health maintenance organization with an exclusive medical group contract and which operates its own pharmacies which are licensed under Code Section 26-4-110.#

3. (3)

   “National average drug acquisition cost” means the monthly survey of retail pharmacies conducted by the federal Centers for Medicare and Medicaid Services to determine average acquisition cost for Medicaid covered outpatient drugs.#

4. (4)

   “Pharmacy” means a pharmacy or pharmacist licensed or holding a nonresident pharmacy permit pursuant to Chapter 4 of Title 26.#

5. (5)

   “Pharmacy benefits manager” or “PBM” means a person, business entity, or other entity that performs pharmacy benefits management as such term is defined in Chapter 64 of Title 33. The term “pharmacy benefits manager” includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a health plan, including operating or administering a prescription card or prescription discount program directly or on behalf of a pharmacy benefits manager or insurer for covered persons for drugs not covered or being reimbursed by the covered person’s pharmacy benefits manager or health plan. Such term shall not include services provided by pharmacies operating under a hospital pharmacy license. Such term shall not include health systems while providing pharmacy services for their patients, employees, or beneficiaries, for indigent care, or for the provision of drugs for outpatient procedures. Such term shall not include services provided by pharmacies affiliated with a facility licensed under Code Section 31-44-4 or a licensed group model health maintenance organization with an exclusive medical group contract and which operates its own pharmacies which are licensed under Code Section 26-4-110.#

6. (6)

   “State health plan” means:#

   1. (A)

      The state employees’ health insurance plan established pursuant to this article;#

   2. (B)

      The health insurance plan for public school teachers and the health insurance plan for public school employees established pursuant to Subparts 2 and 3, respectively, of Part 6 of Article 17 of Chapter 2 of Title 20; and#

   3. (C)

      The health benefit plan established for members, employees, and retirees of the Board of Regents of the University System of Georgia pursuant to Code Section 31-2-4.#

1. (1)

   On and after January 1, 2026, an insurer shall reimburse a pharmacy for a drug dispensed to a covered person for self-administration in the state health plan in an amount equal to:#

   1. (A)

      The national average drug acquisition cost on the day of claim administration or, if unavailable, a discounted percentage of the average wholesale price or wholesale acquisition cost on the day of claim administration as determined by the state health plan based on current competitive market rates or, if unavailable, the wholesale acquisition cost; and#

   2. (B)

      A professional dispensing fee that is not less than $10.50 for chain pharmacies and $11.50 for independent pharmacies.#

2. (2)

   Nothing in this subsection shall prohibit a state health plan from authorizing reimbursement by an insurer to a pharmacy for a drug or drugs in excess of but not lower than the amount required pursuant to paragraph (1) of this subsection.#

An insurer shall not circumvent the requirements regarding pharmacy reimbursement in this Code section in any manner, including without limitation by adjudicating claims through a prescription drug discount card or program.#

The Commissioner of Insurance shall have enforcement authority over this Code section and to take any other actions pursuant to any authority granted under Chapter 64 of Title 33, relating to the regulation and licensure of pharmacy benefits managers. Such authority shall be in addition to any authority granted to the applicable state health plan under contract or law.#