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HB 196

State employees' health insurance plan; drugs dispensed for self-administration; provisions

2025-2026 Regular Session Introduced by Matthew Gambill and 5 co-sponsors

House Bill 196 ensures fair drug pricing for Georgia state employees by mandating transparent reimbursements and protecting beneficiaries from extra costs.

Effective Date
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Bill Summary · HB 196

Summary of House Bill 196 (HB 196)

Purpose and Intent

House Bill 196 aims to amend the state employees' health insurance plan in Georgia to establish a transparent reimbursement structure for drugs dispensed for self-administration. The bill seeks to ensure that covered individuals receive fair pricing for their medications, while also providing a professional dispensing fee to pharmacies.

Key Provisions

  • Reimbursement Structure:

    • Effective January 1, 2026, insurers must reimburse pharmacies for drugs dispensed to covered individuals based on:
    • The national average drug acquisition cost on the day of claim administration, or if unavailable, a discounted percentage of the average wholesale price or wholesale acquisition cost.
    • A professional dispensing fee of at least $10.50 for chain pharmacies and $11.50 for independent pharmacies.

  • Cost Sharing:

    • Insurers are prohibited from passing the cost of the professional dispensing fee onto beneficiaries through cost shares or deductibles. Beneficiaries' out-of-pocket costs will be calculated solely based on the ingredient cost of the prescription drug.

  • Enforcement Authority:

    • The Commissioner of Insurance is granted enforcement authority to ensure compliance with these provisions and to take necessary actions against violations.

  • Definitions:

    • The bill provides specific definitions for terms such as "insurer," "pharmacy," "pharmacy benefits manager," and "state health plan," clarifying the scope of the legislation.

  • Private Right of Action:

    • A violation of this Code section by an insurer allows for a private right of action for damages and equitable remedies for affected pharmacies or beneficiaries.

Affected Parties

  • Pharmacies: Both chain and independent pharmacies will benefit from the established reimbursement rates and professional fees.
  • Covered Individuals: State employees and other beneficiaries under the state health plan will receive fairer pricing for self-administered drugs without additional out-of-pocket costs related to dispensing fees.
  • Insurers: Insurance companies providing health coverage under the state plan will need to adjust their reimbursement practices to comply with the new requirements.

Procedural Timeline

  • Introduced: January 30, 2025
  • House Passed: February 21, 2025
  • Senate Passed: March 27, 2025
  • Signed by Governor: May 14, 2025
  • Effective Date: July 1, 2025

Conclusion

House Bill 196 represents a significant change in how drugs for self-administration are reimbursed under Georgia's state health plan. By mandating a transparent pricing structure and ensuring that beneficiaries are not burdened with additional costs, the bill aims to improve access to necessary medications for state employees and their families.

Compiled from official sources — confirm details with the bill’s official record.

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