Legislative/Regulatory Summary Review of Key Components of Bill 

Jurisdiction:  Georgia

Subject:  Pharmacy Benefit Managers (PBMs)

 

Version date:  5/7/21

---

Law/Regulation:          Adds requirements for PBMs operating in GA effective January 1, 2021, with enforcement applying to contracts issued on or after July 1, 2021.   A more detailed review is attached.

 

Main Provisions:

Section 2:     Licensing and Filing Fees

 

Must have a GA license.  

A licensed PBM shall not market or administer any insurance product not approved in Georgia or that is issued by a non-admitted insurer or unauthorized multiple employer self-insured health plan.

Penalties and sanctions apply for non-conformance

Section 3:     Prohibition on the Practice of Medicine

 

PBMs shall not engage in the practice of medicine.    Physicians can be hired as advisors if they meet the following criteria 

  1. Have actively seen patients within the past five years; and
  2. Have practiced in the same specialty area for which he or she is providing advisement within the past five years

Section 4:     Commissioner Enforcement

Upon receipt of a complaint and verification that a violation occurred, the Commissioner may conduct a compliance audit to identify presence of any similar violations in the state

Section 5:     Reporting and Disclosure of Reimbursements

PBMs must file all methodologies they use in determining the maximum allowable cost for appeals.  The Commissioner is required to treat these as confidential and cannot be disclosed.  There are multiple requirements to supply specific data e.g. acquisition costs, drugs dispensed, quantity, reimbursements, etc.

Section 5:  Reporting and Disclosure of Reimbursements (continued)

On or after July 1, 2021, PBM shall not:

  • Discriminate in reimbursement, assess any fees or adjustments, or exclude a pharmacy from the PBM’s network on the basis that the pharmacy 
  • Engage in any practice that:
    1. Patient outcome reimbursement ;
    2. Includes a point-of-sale fee or retroactive fee;
    3. Derives revenue from pharmacy or insured in connection with performing PBM services (does not include receipt of deductibles or copayments)

Main Provisions:

Section 6:  Claims Administration

Prohibits exclusivity requirement to obtain pharmaceutical services through a single mail-order distributor without providing a comparison to other providers of service.

PBMs shall offer a health plan the ability to receive 100% of all rebates it receives from pharmaceutical manufacturers.     

A PBM shall offer a health plan the option of charging the plan the same price for a prescription drug as it pays a pharmacy for the prescription drug 

PBMs must take into consideration any out-of-pocket maximum, deductible, or copayment responsibility when calculating the insured’s contribution.  Further, the PBM shall include any amount paid to the insured or on his or her behalf through a third-party payment, financial assistance, discount, or product voucher that not have a generic equivalent 

This section does not apply to HMOs licensed under Code Section 26-4-110.

Section 7:     Prohibited Activities of PBM

Provides an extensive list of prohibitions that essential represent conflict of interest behaviors, improper incentives, fees etc. 

Does not apply to HMO with an exclusive medical group contract and that operates its own pharmacies.  Also, does not prohibit a PBM from entering into an agreement with an affiliated pharmacy or an affiliated pharmacy of another licensed PBM.

Section 8:     Findings of the General Assembly and Focus of this Chapter

  1. The practice of steering by a PBM represents a conflict of interest;
  2. The practice of imposing point-of-sale fees or retroactive fees obscures the true cost of prescription drugs in this state;
  • Surcharges apply to those in violation of these provisions

Preemption:

 

Federal, law, rule or regulation takes precedence if anything in this rule is inconsistent or conflicts with Federal law

 

Other General Comments or Considerations

To be determined based on specific concerns.

 

Resources

GA SB 313 Law Text

GA 33-30-4.3 – Utilization of mail-order pharmaceutical distributor

Pharmacy Audit Bill of Rights Code Section 26-4-118