(Effective January 1, 2021) Reimbursement Methodologies Utilized by Pharmacy Benefits Managers

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  2. Georgia Code
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  4. Regulation and Licensure of Pharmacy Benefits Managers
  5. (Effective January 1, 2021) Reimbursement Methodologies Utilized by Pharmacy Benefits Managers

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    1. Any methodologies utilized by a pharmacy benefits manager in connection with reimbursement pursuant to Code Section 33-64-9 shall be filed with the Commissioner for use in determining maximum allowable cost appeals; provided, however, that methodologies not otherwise subject to disclosure under Article 4 of Chapter 18 of Title 50 shall be treated as confidential and shall not be subject to disclosure.
    2. A pharmacy benefits manager shall utilize the national average drug acquisition cost as a point of reference for the ingredient drug product component of a pharmacy's reimbursement for drugs appearing on the national average drug acquisition cost list and shall produce a report every four months, which shall be provided to the Commissioner and published by the pharmacy benefits manager on a website available to the public for no less than 24 months, of all drugs appearing on the national average drug acquisition cost list reimbursed 10 percent and below the national average drug acquisition cost, as well as all drugs reimbursed 10 percent and above the national average drug acquisition cost. For each drug in the report, a pharmacy benefits manager shall include the month the drug was dispensed, the quantity of the drug dispensed, the amount the pharmacy was reimbursed per unit or dosage, whether the dispensing pharmacy was an affiliate, whether the drug was dispensed pursuant to a state or local government health plan, and the average national average drug acquisition cost for the month the drug was dispensed. Such report shall exclude drugs dispensed pursuant to 42 U.S.C. Section 256b.
    3. This subsection shall not apply to Medicaid under Chapter 4 of Title 49 when the department reimburses providers directly for each covered service; provided, however, that it shall apply to Medicaid managed care programs administered through care management organizations.
    4. This subsection shall take effect on January 1, 2021; provided, however, that prior to July 1, 2021, upon written request, a pharmacy benefits manager shall be granted an extension by the Commissioner of up to six months for its initial filing required pursuant to paragraph (1) of this subsection if the pharmacy benefits manager certifies it is in need of such extension.
  2. On and after July 1, 2021, a pharmacy benefits manager shall not:
    1. Discriminate in reimbursement, assess any fees or adjustments, or exclude a pharmacy from the pharmacy benefit manager's network on the basis that the pharmacy dispenses drugs subject to an agreement under 42 U.S.C. Section 256b; or
    2. Engage in any practice that:
      1. In any way bases pharmacy reimbursement for a drug on patient outcomes, scores, or metrics; provided, however, that nothing shall prohibit pharmacy reimbursement for pharmacy care, including dispensing fees from being based on patient outcomes, scores, or metrics so long as the patient outcomes, scores, or metrics are disclosed to and agreed to by the pharmacy in advance;
      2. Includes imposing a point-of-sale fee or retroactive fee; or
      3. Derives any revenue from a pharmacy or insured in connection with performing pharmacy benefits management services; provided, however, that this shall not be construed to prohibit pharmacy benefits managers from receiving deductibles or copayments.
  3. This Code section shall also apply to pharmacy benefits managers' reimbursements to dispensers.

(Code 1981, §33-64-9.1, enacted by Ga. L. 2020, p. 768, § 5/HB 946; Ga. L. 2020, p. 780, § 5/SB 313.)

Editor's notes.

- Ga. L. 2020, p. 768, § 5/HB 946 and Ga. L. 2020, p. 780, § 5/SB 313, both enacted a Code section designated 33-64-9.1 and contained identical provisions.

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.

U.S. Code.

- Section 256b of 42 U.S.C., referred to in this Code section, concerns the limitation on prices of drugs purchased by covered entities.


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