Utilization of Mail-Order Pharmaceutical Distributors in Policies, Plans, Contracts, or Funds; Utilization of Other Providers of Pharmaceutical Services Under Same Terms and Conditions

  1. Law
  2. Georgia Code
  3. Insurance
  4. Group or Blanket Accident and Sickness Insurance
  5. General Provisions
  6. Utilization of Mail-Order Pharmaceutical Distributors in Policies, Plans, Contracts, or Funds; Utilization of Other Providers of Pharmaceutical Services Under Same Terms and Conditions

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  1. For the purposes of this Code section, the term "health care insurer" means an insurer, including a fraternal benefit society, a health care plan, or a health maintenance organization authorized to sell accident and sickness insurance policies, subscriber certificates, or other contracts of accident and sickness insurance by whatever name called.
  2. A group or blanket accident and sickness insurance policy, plan, contract, or fund may not be issued, delivered, issued for delivery, or renewed by a health care insurer if such policy, plan, contract, or fund requires that insureds thereunder obtain pharmaceutical services, including prescription drugs, exclusively from a mail-order pharmaceutical distributor.Insureds who do not utilize a mail-order pharmaceutical distributor shall not be required to pay a different copayment fee or have imposed any varying conditions for the receipt of pharmaceutical services, including prescription drugs, when that payment or condition is not imposed upon those insureds who utilize a mail-order pharmaceutical distributor for those services if the provider of pharmaceutical services utilized by the insured has agreed to the same terms and conditions as applicable to the mail-order pharmaceutical distributor and has agreed to accept payment or reimbursement from the health care insurer at no more than the same amount which would have been paid to the mail-order pharmaceutical distributor for the same pharmaceutical services.
  3. Any health care insurer who issues a group or blanket accident and sickness policy, plan, contract, or fund that provides coverage for pharmaceutical services, including prescription drugs, by a mail-order pharmaceutical distributor shall issue to each insured under such policy, plan, contract, or fund an explanation of the payment or reimbursement method applicable to mail-order pharmaceutical distributors as compared to other providers of pharmaceutical services. For those health care insurers which provide benefit booklets to their insureds, the inclusion of such an explanation in any such benefit booklet shall constitute compliance with this subsection.
  4. Any health care insurer who contracts with a mail-order pharmaceutical distributor to provide pharmaceutical services, including prescription drugs, under a group or blanket accident and sickness policy, plan, contract, or fund shall include in such contract a provision requiring the mail-order pharmaceutical distributor in its initial written correspondence with an insured to include a notice that the insured may obtain pharmaceutical services, including prescription drugs, from other providers of pharmaceutical services and that the exclusive utilization of the mail-order pharmaceutical distributor is not required.
  5. A provider of pharmaceutical services who desires to provide services to insureds in their service area shall, upon written request to the health care insurer, be provided information pertaining to the terms and conditions applicable to mail-order pharmaceutical services available in such service area.If the provider of pharmaceutical services agrees to such terms and conditions in writing and agrees to be paid or reimbursed at no more than the same amount which would be paid to a mail-order pharmaceutical distributor for the same services, the provider of pharmaceutical services will be paid or reimbursed at no more than the same amount paid to the mail-order pharmaceutical distributor for the same pharmaceutical services.

(Code 1981, §33-30-4.3, enacted by Ga. L. 1991, p. 1901, § 1; Ga. L. 2017, p. 164, § 44/HB 127; Ga. L. 2019, p. 386, § 100/SB 133.)

The 2019 amendment, effective July 1, 2019, deleted "on or after July 1, 1991," following "health care insurer" in the middle of the first sentence of subsection (b).


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