Bill > HB810

This bill mandates that pharmacy benefits managers (PBMs), which are companies that manage prescription drug benefits on behalf of health insurers, must reimburse eligible pharmacies for prescription drugs based on specific formulas. An "eligible pharmacy" is defined as one not owned by an entity that owns more than ten pharmacies. The reimbursement must be equal to the national average drug acquisition cost at the time the drug was dispensed, plus a professional dispensing fee set by the Georgia Medicaid program. If the national average cost isn't available, the reimbursement will be based on the wholesale acquisition cost as of January 1, 2026, plus the same dispensing fee. This rule does not apply to state health plans or Medicaid programs, including managed care. However, PBMs are allowed to reimburse rural pharmacies, defined as eligible pharmacies in counties with fewer than 50,000 residents, at a rate higher than the mandated formula, with exceptions for affiliate, mail-order, and specialty pharmacies. The bill also clarifies that these reimbursement calculations should not be affected by "effective rate guarantees," which are contractual provisions allowing PBMs to adjust reimbursement rates to ensure an average predetermined rate. This legislation is set to take effect on July 1, 2027.