2019 Georgia Code
Title 33 - Insurance
Chapter 64 - Regulation and Licensure of Pharmacy Benefits Managers
§ 33-64-11. Prohibited activities of pharmacy benefits manager

• (a) 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) Prohibiting a pharmacist, pharmacy, or other dispenser or dispenser practice from offering and providing store direct 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) 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 or pay for performance recoupments otherwise permitted by law;

  • (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) Ordering an insured for the filling of a prescription or the provision of pharmacy care services to an affiliated pharmacy; offering or implementing plan designs that require patients to utilize an affiliated pharmacy; or advertising, marketing, or promoting a pharmacy by an affiliate to patients or prospective patients. Subject to the foregoing, a pharmacy benefits manager may include an affiliated pharmacy in communications to patients, including patient and prospective patient specific communications, regarding network pharmacies and prices, provided that the pharmacy benefits manager includes information regarding eligible nonaffiliated pharmacies in such communications and the information provided is accurate. This paragraph shall not be construed to prohibit a pharmacy benefits manager from entering into an agreement with an affiliated pharmacy to provide pharmacy care to patients. The restrictions in this paragraph shall not apply to limited distribution prescription drugs requiring special handling and not commonly carried at retail pharmacies or oncology clinics or practices;

  • (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) Knowingly making a misrepresentation to an insured, pharmacist, pharmacy, dispenser, or dispenser practice; and

  • (10) Taking any action in violation of subparagraphs (a)(21)(D) and (a)(21)(E) of Code Section 26-4-28.

• (b) 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.

• (c) This Code section shall not apply to:

  • (1) A care management organization, as defined in Chapter 21A of this title;

  • (2) The Department of Community Health, as defined in Chapter 2 of Title 31;

  • (3) The State Health Benefit Plan under Article 1 of Chapter 18 of Title 45; or

  • (4) Any licensed group model health maintenance organization with an exclusive medical group contract and which operates its own pharmacies licensed under Code Section 26-4-110.1.

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.