(For Effective Date, See note.) Definitions

  1. Law
  2. Georgia Code
  3. Insurance
  4. Regulation and Licensure of Pharmacy Benefits Managers
  5. (For Effective Date, See note.) Definitions

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As used in this chapter, the term:

  1. "Affiliate pharmacy" means a pharmacy which, either directly or indirectly through one or more intermediaries:
    1. Has an investment or ownership interest in a pharmacy benefits manager licensed under this chapter;
    2. Shares common ownership with a pharmacy benefits manager licensed under this chapter; or
    3. Has an investor or ownership interest holder which is a pharmacy benefits manager licensed under this chapter.
  2. "Business entity" means a corporation, association, partnership, sole proprietorship, limited liability company, limited liability partnership, or other legal entity.
  3. "Dispenser" shall have the same meaning as in paragraph (10) of Code Section 16-13-21.
  4. "Health plan" means an individual or group plan or program which is established by contract, certificate, law, plan, policy, subscriber agreement, or any other method and which is entered into, issued, or offered for the purpose of arranging for, delivering, paying for, providing, or reimbursing any of the costs of health care or medical care, including pharmacy services, drugs, or devices. Such term includes any health care coverage provided under the state health benefit plan pursuant to Article 1 of Chapter 18 of Title 45; the medical assistance program pursuant to Article 7 of Chapter 4 of Title 49; the PeachCare for Kids Program pursuant to Article 13 of Chapter 5 of Title 49; and any other health benefit plan or policy administered by or on behalf of this state.
  5. "Health system" means a hospital or any other facility or entity owned, operated, or leased by a hospital and a long-term care home.
  6. "Insured" means a person who receives prescription drug benefits administered by a pharmacy benefits manager.
  7. "Maximum allowable cost" means the per unit amount that a pharmacy benefits manager reimburses a pharmacist for a prescription drug, excluding dispensing fees and copayments, coinsurance, or other cost-sharing charges, if any.
  8. "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.
  9. "Pharmacy" means a pharmacy or pharmacist licensed pursuant to Chapter 4 of Title 26 or another dispensing provider.
  10. "Pharmacy benefits management" means the administration of a plan or program that pays for, reimburses, and covers the cost of drugs, devices, or pharmacy care to insureds on behalf of a health plan. The term shall not include the practice of pharmacy as defined in Code Section 26-4-4.
  11. "Pharmacy benefits manager" means a person, business entity, or other entity that performs pharmacy benefits management. The term 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. The term does not include services provided by pharmacies operating under a hospital pharmacy license. The term also does 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. The term also does 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.
  12. "Point-of-sale fee" means all or a portion of a drug reimbursement to a pharmacy or other dispenser withheld at the time of adjudication of a claim for any reason.
  13. "Rebate" means any and all payments that accrue to a pharmacy benefits manager or its health plan client, directly or indirectly, from a pharmaceutical manufacturer, including but not limited to discounts, administration fees, credits, incentives, or penalties associated directly or indirectly in any way with claims administered on behalf of a health plan client.
  14. "Retroactive fee" means all or a portion of a drug reimbursement to a pharmacy or other dispenser recouped or reduced following adjudication of a claim for any reason, except as otherwise permissible as described in Code Section 26-4-118.
  15. "Steering" means:
    1. Ordering an insured to use its affiliate pharmacy for the filling of a prescription or the provision of pharmacy care;
    2. Ordering an insured to use an affiliate pharmacy of another pharmacy benefits manager licensed under this chapter pursuant to an arrangement or agreement for the filling of a prescription or the provision of pharmacy care;
    3. Offering or implementing plan designs that require an insured to utilize its affiliate pharmacy or an affiliate pharmacy of another pharmacy benefits manager licensed under this chapter or that increases plan or insured costs, including requiring an insured to pay the full cost for a prescription when an insured chooses not to use any affiliate pharmacy; or
    4. Advertising, marketing, or promoting its affiliate pharmacy or an affiliate pharmacy of another pharmacy benefits manager licensed under this chapter to insureds. Subject to the foregoing, a pharmacy benefits manager may include its affiliated pharmacy or an affiliate pharmacy of another pharmacy benefits manager licensed under this chapter in communications to patients, including patient and prospective patient specific communications, regarding network pharmacies and prices, provided that the pharmacy benefits manager includes information regarding eligible nonaffiliated pharmacies in such communications and that the information provided is accurate.

(Code 1981, §33-64-1, enacted by Ga. L. 2010, p. 757, § 1/SB 310; Ga. L. 2015, p. 337, § 2/HB 470; Ga. L. 2019, p. 533, § 1-34/HB 99; Ga. L. 2019, p. 940, § 1/HB 323; Ga. L. 2020, p. 768, § 1/HB 946; Ga. L. 2020, p. 780, § 1/SB 313.)

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 2019, paragraph (4.1) was redesignated as paragraph (3.1) to maintain alphabetical order.

Editor's notes.

- Ga. L. 2019, p. 940, § 4/HB 323 not codified by the General Assembly, provides, in part, that this Act shall apply to all contracts issued, delivered, or issued for delivery in this state on and after January 1, 2020.

Ga. L. 2020, p. 768, § 9(b)/HB 946 and Ga. L. 2020, p. 780, § 9(b)/SB 313, not codified by the General Assembly, provide that the amendment to this Code section is applicable to all contracts issued, delivered, or issued for delivery in this state on and after January 1, 2021.


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