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

Minimum pharmacy payments for Georgia state plans

Beginning January 1, 2026, Georgia state-plan insurers must meet minimum pharmacy payments for drugs members take themselves. This covers plans for state employees, public school teachers and employees, and University System members, employees, and retirees. Payments use the national average drug acquisition cost on the day the claim is processed. If unavailable, the plan sets a market-based discount from average wholesale price or wholesale acquisition cost; the final fallback is wholesale acquisition cost. Payments also include at least $10.50 for dispensing at chain pharmacies or $11.50 at independent pharmacies; insurers can pay more. Insurers cannot bypass these rules through discount cards or other methods, and Georgia’s Insurance Commissioner can enforce them. The law excludes qualifying group-model health maintenance organizations that use only their own pharmacy network. It also excludes certain hospital, health-system, and facility-affiliated pharmacy services from its pharmacy benefit manager definition. These are pharmacy payment rules, not a specified change to members’ copays or other out-of-pocket costs.