(For Effective Date, See note.) Prohibited Activities of Pharmacy Benefits Manager

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

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  1. A pharmacy benefits manager shall be proscribed from:
    1. Prohibiting a pharmacist, pharmacy, or other dispenser or dispenser practice from providing an insured individual information on the amount of the insured's cost share for such insured's prescription drug and the clinical efficacy of a more affordable alternative drug if one is available. No pharmacist, pharmacy, or other dispenser or dispenser practice shall be penalized by a pharmacy benefits manager for disclosing such information to an insured or for selling to an insured a more affordable alternative if one is available;
    2. (For effective date, see note.) Prohibiting a pharmacist, pharmacy, or other dispenser or dispenser practice from offering and providing delivery services to an insured as an ancillary service of the pharmacy or dispenser practice;
    3. Charging or collecting from an insured a copayment that exceeds the total submitted charges by the network pharmacy or other dispenser practice for which the pharmacy or dispenser practice is paid;
    4. (For effective date, see note.) Charging or holding a pharmacist or pharmacy or dispenser or dispenser practice responsible for a fee or penalty relating to the adjudication of a claim or an audit conducted pursuant to Code Section 26-4-118, provided that this shall not restrict recoupments made in accordance with Code Section 26-4-118;
    5. Recouping funds from a pharmacy in connection with claims for which the pharmacy has already been paid without first complying with the requirements set forth in Code Section 26-4-118, unless such recoupment is otherwise permitted or required by law;
    6. Penalizing or retaliating against a pharmacist or pharmacy for exercising rights under this chapter or Code Section 26-4-118;
    7. (For effective date, see note.) Steering. This paragraph shall not be construed to prohibit a pharmacy benefits manager from entering into an agreement with an affiliated pharmacy or an affiliated pharmacy of another pharmacy benefits manager licensed pursuant to this chapter to provide pharmacy care to patients;
    8. Transferring or sharing records relative to prescription information containing patient-identifiable and prescriber-identifiable data to an affiliated pharmacy for any commercial purpose; provided, however, that nothing shall be construed to prohibit the exchange of prescription information between a pharmacy benefits manager and an affiliated pharmacy for the limited purposes of pharmacy reimbursement, formulary compliance, pharmacy care, or utilization review;
    9. (For effective date, see note.) Knowingly making a misrepresentation to an insured, pharmacist, pharmacy, dispenser, or dispenser practice;
    10. (For effective date, see note.) Taking any action in violation of subparagraphs (a)(21)(D) and (a)(21)(E) of Code Section 26-4-28 or charging a pharmacy a fee in connection with network enrollment;
    11. (For effective date, see note.) Withholding coverage or requiring prior authorization for a lower cost therapeutically equivalent drug available to an insured or failing to reduce an insured's cost share when an insured selects a lower cost therapeutically equivalent drug; and
    12. (For effective date, see note.) Removing a drug from a formulary or denying coverage of a drug for the purpose of incentivizing an insured to seek coverage from a different health plan.
  2. To the extent that any provision of this Code section is inconsistent or conflicts with applicable federal law, rule, or regulation, such applicable federal law, rule, or regulation shall apply.
  3. (For effective date, see note.) 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.

(Code 1981, §33-64-11, enacted by Ga. L. 2017, p. 494, § 2/HB 276; Ga. L. 2017, p. 497, § 2/SB 103; Ga. L. 2019, p. 940, § 3/HB 323; Ga. L. 2020, p. 654, § 5/HB 918; Ga. L. 2020, p. 768, § 7/HB 946; Ga. L. 2020, p. 780, § 7/SB 313.)

Editor's notes.

- Ga. L. 2017, p. 494, § 2/HB 276 and Ga. L. 2017, p. 497, § 2/SB103 both enacted a Code section designated 33-64-11 and containing identical provisions.

Ga. L. 2017, p. 494, § 3/HB 276 and Ga. L. 2017, p. 497, § 3/SB 103, not codified by the General Assembly, provides that this Code section shall apply to all contracts issued, delivered, or issued for delivery in this state on and after July 1, 2017.

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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