Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-97 - PHARMACY BENEFITS MANAGERS REGULATION
Rule 120-2-97-.07 - Forms; reports; and required documentation

Universal Citation: GA Rules and Regs r 120-2-97-.07

Current through Rules and Regulations filed through September 23, 2024

(1) Standard pharmacy benefits manager forms are required and will be supplied upon request by the Commissioner's office either in paper form or electronically over the internet. Applicants and licensed pharmacy benefits managers shall utilize all applicable forms in preparing applications, statements, notices of required information, and other required submissions required under Chapter 64 of Title 33 of the Official Code of Georgia Annotated.

(2) A pharmacy benefits manager shall file all methodologies utilized in determining multi-source generic drug pricing reimbursement to pharmacies in this state within 30 days of their use and upon receiving a notice of complaint by the Commissioner in connection with O.C.G.A. § 33-64-9, a pharmacy benefits manager shall within 14 calendar days:

(a) Identify the methodology and source or sources used to determine the multi-source generic drug price for the drug which is the subject of the complaint; and

(b) Identify the reason for the denial of any pharmacy reimbursement appeal and produce relevant documentation in connection with the reimbursement price of the drug the day the claim at issue in the complaint was adjudicated and the preceding 5 days prior to the day the claim was adjudicated including source pricing records as well the national drug code of an equivalent drug product that could have been purchased by the complainant pharmacy at a price at or below the amount the pharmacy was reimbursed;

(3) A pharmacy benefits manager shall annually file a disclosure statement identifying all affiliate pharmacies holding a Georgia license or non-resident pharmacy and upon receiving a notice of complaint by the Commissioner in connection with steering or a mail order mandate, a pharmacy benefits manager shall provide within five business days:

(a) Any and all communications sent to the insured within the previous 12 months advertising, marketing, promoting an affiliate pharmacy or the affiliate pharmacy of another pharmacy benefits manager; any communication ordering an insured to use an affiliate pharmacy benefits manager or indicating that an insured's costs will increase when using a non-affiliate pharmacy; and

(b) Any and all communications sent to a non-affiliate pharmacy when an insured attempted to fill a prescription including any on-screen rejections or other messaging directing an insured to an affiliate pharmacy or affiliate of another pharmacy benefits manager.

(4) As required by O.C.G.A. Section 33-64-9.1(a)(2), a pharmacy benefits manager shall annually file on a form provided by the Commissioner:

(a) The required NADAC report for the months of January through April no later than June 15, for the months May through August no later than October 15, and for the months of September through December no later than February 15 of the following year; and

(b) on or before March 1, the website domain name where the public can access the pharmacy benefits manager's NADAC reports. Any changes to the domain name thereafter shall be filed with the Commissioner within 14 calendar days of the change.

(5) As required by O.C.G.A. Code Section 33-64-10(a), a pharmacy benefits manager shall, for each health plan client, annually, on or before the first day of April, on a form provided by the Commissioner report all rebates and other payments it received in the preceding calendar year from pharmaceutical manufacturers on behalf of the health plan.

(6) As required by O.C.G.A. Code Section 33-64-10(d), a pharmacy benefits manager shall, report for any health plan administered on behalf of a state agency or political subdivision of the state, state department or subdivision of the state, on or before March first, the aggregate difference between what the pharmacy benefits manager reimbursed pharmacies and what the pharmacy benefits managers we paid by the health plan. Nothing herein shall be construed to authorize a pharmacy benefits manager charging a state health plan or political subdivision of the state health plan more for a prescription drug than it reimburses a pharmacy after July of 2021.

(7) As required by O.C.G.A. Section 33-64-12, a pharmacy benefits manager and a person operating a health plan under Title 33 shall:

(a) Annually, on or before March 1, file on a form provided by the Commissioner, an attestation indicating whether or not, in the previous calendar year, it or its contracted pharmacy benefits manager engaged in the practice of steering or imposed point of sale or retroactive fees in connection with its health plans and Georgia insureds; and

(b) Annually, on or before March 1, file a report detailing all prescription drug claims it or its contracted pharmacy benefits manager administered for Georgia insureds on behalf of each health plan including the date each claim was administered, the amount the pharmacy was reimbursed for the claim, and the aggregate dollar amount it reimbursed pharmacies in the previous calendar year for prescriptions drugs for Georgia insureds on behalf of all its health plan clients.

(c) If it has engaged in the practice of steering or has imposed point of sale or retroactive fees, annually, on or before April 1, render to the state of Georgia, a surcharge equal to 10% of the aggregate dollar amount it or its contracted pharmacy benefits manager reimbursed pharmacies in the previous calendar year for prescriptions drugs for Georgia insureds.

(d) Any and all claims administered pursuant to the Medicare program shall be exempt from reporting requirements and shall be exempt from the surcharge calculation. All other claims administered on behalf of a Georgia insured shall be subject to reporting and, when a pharmacy benefits manager has engaged in the practice of steering or has imposed a point of sale or retroactive fee, the surcharge.

(8) upon receiving a notice of complaint by the Commissioner regarding an audit in connection with O.C.G.A. Code Section 26-4-118, a pharmacy benefits manager shall identify within 14 calendar days, on a form provided by the Commissioner, the notice given to the pharmacy, the number of claims audited during the audit at issue, the number of claims audited within the past 12 months, the number of audits of the pharmacy within the past 12 months, the discrepancies identified in the audit at issue, the basis for the denial of any internal appeal, and the basis for recoupment.

O.C.G.A. §§ 33-2-9, 33-64-7.

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