(Effective July 1, 2021) Administration of Claims by Pharmacy Benefits Manager

  1. Law
  2. Georgia Code
  3. Insurance
  4. Regulation and Licensure of Pharmacy Benefits Managers
  5. (Effective July 1, 2021) Administration of Claims by Pharmacy Benefits Manager

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  1. A pharmacy benefits manager shall administer claims in compliance with Code Section 33-30-4.3 and shall not require insureds to use a mail-order pharmaceutical distributor including a mail-order pharmacy.
  2. A pharmacy benefits manager shall offer a health plan the ability to receive 100 percent of all rebates it receives from pharmaceutical manufacturers. In addition, a pharmacy benefits manager shall report annually to each health plan and the department the aggregate amount of all rebates and other payments that the pharmacy benefits manager received from pharmaceutical manufacturers in connection with claims if administered on behalf of the health plan.
  3. A pharmacy benefits manager shall offer a health plan the option of charging such health plan the same price for a prescription drug as it pays a pharmacy for the prescription drug; provided, however, that a pharmacy benefits manager shall charge a health benefit plan administered by or on behalf of the state or a political subdivision of the state, including any county or municipality, the same price for a prescription drug as it pays a pharmacy for the prescription drug.
  4. A pharmacy benefits manager shall report in the aggregate to a health plan the difference between the amount the pharmacy benefits manager reimbursed a pharmacy and the amount the pharmacy benefits manager charged a health plan. Such information shall be confidential and shall not be subject to Article 4 of Chapter 18 of Title 50, relating to open records; provided, however, that such information as it relates to health plans administered by or through the Department of Community Health, including Medicaid care management organizations, or any other state agency shall not be confidential and shall be subject to disclosure under Article 4 of Chapter 18 of Title 50.
  5. When calculating an insured's contribution to any out-of-pocket maximum, deductible, or copayment responsibility, a pharmacy benefits manager shall include any amount paid by the insured or paid on his or her behalf through a third-party payment, financial assistance, discount, or product voucher for a prescription drug that does not have a generic equivalent or that has a generic equivalent but was obtained through prior authorization, a step therapy protocol, or the insurer's exceptions and appeals process. Nothing in this subsection shall be construed to require that a pharmacy benefits manager accept a third-party payment, financial assistance, discount, or product voucher submitted on behalf of an insured.
  6. This Code section shall not apply to 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.
  7. As used in this Code section, the term "generic equivalent":
    1. Means a drug that has an identical amount of the same active chemical ingredients in the same dosage form, that meets applicable standards of strength, quality, and purity according to the United States Pharmacopeia or other nationally recognized compendium, and that, if administered in the same amounts, will provide comparable therapeutic effects; and
    2. Does not include a drug that is listed by the federal Food and Drug Administration as having unresolved bioequivalence concerns according to the administration's most recent publication of approved drug products with therapeutic equivalence evaluations.

(Code 1981, §33-64-10, enacted by Ga. L. 2017, p. 494, § 2/HB 276; Ga. L. 2017, p. 497, § 2/SB 103; Ga. L. 2019, p. 940, § 2/HB 323; Ga. L. 2020, p. 493, § 33/SB 429; Ga. L. 2020, p. 654, § 4/HB 918; Ga. L. 2020, p. 768, § 6/HB 946; Ga. L. 2020, p. 780, § 6/SB 313.)

Editor's notes.

- Ga. L. 2020, p. 768, § 9(a)/HB 946 and Ga. L. 2020, p. 780, § 9(a)/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 July 1, 2021.


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