State employees' health insurance plan; drugs dispensed for self-administration; provisions
Summary
HB 196 amends Georgia law governing the state health plan to change how pharmacies are reimbursed for drugs dispensed for self-administration to covered members. Beginning January 1, 2026, the bill requires insurers or other entities administering the state health plan to reimburse pharmacies using a transparent, index-based pricing method tied primarily to the National Average Drug Acquisition Cost (NADAC). If NADAC is unavailable, reimbursement must be based on a discounted percentage of average wholesale price or wholesale acquisition cost, or, if necessary, wholesale acquisition cost itself.
In addition to the drug ingredient cost, the bill sets minimum professional dispensing fees of $10.50 for chain pharmacies and $11.50 for independent pharmacies. It also bars insurers from avoiding these reimbursement rules by routing claims through prescription discount cards or similar programs. The Commissioner of Insurance is given enforcement authority, alongside any authority already available under pharmacy benefits manager regulation laws.
Impact
The bill directly affects the state employees’ health insurance plan, the public school teachers’ and employees’ health plans, and the University System of Georgia health benefit plan. It creates a statutory reimbursement floor for pharmacy claims in those plans and expands the Commissioner of Insurance’s enforcement role over compliance. The measure also interacts with existing pharmacy benefits manager regulation in Title 33 and may alter plan administration, pharmacy contracts, and payment practices for PBMs, insurers, chain pharmacies, and independent pharmacies serving state plan members.
Sentiment
The bill appears to have broad bipartisan support and little visible opposition. It passed the House 168-0, passed the Senate by substitute 55-0, and the House then agreed to the Senate substitute 166-0. The unanimous votes suggest the legislation was viewed favorably as a pharmacy reimbursement and transparency measure, with consensus across both chambers.
Contention
No committee transcript was provided, and the recorded votes show no floor opposition. The main policy issue implicit in the bill is how to balance lower, more transparent reimbursement benchmarks against pharmacy payment adequacy. Independent pharmacies are specifically protected by a higher dispensing fee than chain pharmacies, indicating concern about pharmacy margins and access, while the inclusion of PBMs and discount-card circumvention language suggests concern about opaque pricing practices and claim-adjudication workarounds.
Employees' Insurance and Benefits Plans; expenses for gender-affirming care under the state health benefit plan or with any state funds; prohibit coverage
Health insurance; creating the Employer Health Plan Transparency Act; prohibiting health plans from entering certain contracts; prohibiting certain contract provisions. Effective date.
Prohibit certain provisions in insurance policies and health plans relating to clinician-administered drugs and change provisions relating to pharmacy benefit managers