Georgia sets new pharmacy reimbursement rules effective January 2025

House Bill 810, introduced in the Georgia House Legislature on March 20, 2025, aims to reform the reimbursement practices of pharmacy benefits managers (PBMs) to ensure fair compensation for pharmacies. The bill mandates that PBMs must reimburse pharmacies at least the wholesale acquisition cost of prescription drugs, plus a professional dispensing fee of $10.64, effective January 1, 2025. This fee will automatically adjust annually based on the Consumer Price Index for medical care, ensuring that pharmacies are not underpaid for their services.

A significant aspect of the bill is its prohibition against PBMs offering lower reimbursement rates to non-affiliated pharmacies compared to their affiliated counterparts, promoting a level playing field in the pharmacy market. Additionally, any reimbursements made under this new provision will be excluded from existing rate guarantees, which could impact how PBMs negotiate with pharmacies.

The bill has sparked notable debates among stakeholders. Supporters argue that it addresses long-standing issues of underpayment and inequity in pharmacy reimbursements, potentially improving access to medications for patients. Critics, however, express concerns that the bill may lead to increased costs for health plans and consumers, as PBMs might pass on the higher reimbursement rates.

The implications of House Bill 810 are significant, as it could reshape the landscape of pharmacy reimbursements in Georgia. Experts suggest that if passed, the bill may lead to enhanced financial stability for independent pharmacies, which have struggled under current reimbursement models. However, the potential for increased healthcare costs remains a contentious point that could influence future legislative discussions.

As the bill moves through the legislative process, its fate will depend on ongoing negotiations and the responses from various stakeholders, including healthcare providers, insurers, and consumer advocacy groups. The outcome could set a precedent for similar reforms in other states, making House Bill 810 a pivotal piece of legislation in the ongoing conversation about healthcare affordability and access.