Georgia Medicaid PBM Oversight (2026): Spread Pricing, PDL, 340B, Prior Auth, Transparency

::hero{eyebrow="Georgia Medicaid" headline="Georgia Medicaid Pharmacy Benefit Manager Oversight" subhead="How Pharmacy Benefit Managers (PBMs) administer the Medicaid prescription drug benefit through claims processing, network contracting, prior authorization, step therapy, formulary management, rebate negotiation, and specialty pharmacy operations. How Section 1927 of the Social Security Act governs the Medicaid Drug Rebate Program. How Section 340B of the Public Health Service Act provides discounted drugs to FQHCs and other safety-net providers. How the Consolidated Appropriations Act of 2023 strengthened PBM transparency in Medicaid managed care. How DCH operates the statewide Georgia Preferred Drug List. How O.C.G.A. §33-64 regulates PBMs operating in Georgia. And how Georgia families navigate PBM-driven access barriers to the medications they need."} ::

Pharmacy Benefit Managers (PBMs) are the third-party administrators that sit between Medicaid programs, Care Management Organizations, pharmaceutical manufacturers, and pharmacies. PBMs administer the day-to-day operations of the prescription drug benefit. They process claims at the point of dispensing. They contract with networks of retail, specialty, mail-order, and long-term care pharmacies. They set pharmacy reimbursement rates (the "ingredient cost" plus a dispensing fee). They negotiate manufacturer rebates in exchange for preferred placement on the formulary. They administer prior authorization, step therapy, quantity limits, and formulary tiering. They manage specialty pharmacy arrangements for high-cost injectable, infused, and oral specialty drugs. They coordinate with 340B covered entities on contract pharmacy arrangements. They run Drug Utilization Review programs.

PBMs have substantial market power. Three vertically integrated PBMs (CVS Caremark, Express Scripts, OptumRx) administer the majority of U.S. prescription drug claims. PBM practices have been the subject of intense federal and state regulatory attention over the last decade, with focus on spread pricing (the gap between what PBMs bill plans and what they pay pharmacies), manufacturer rebate retention, vertical integration with retail pharmacies, mandatory mail-order policies, and transparency.

In Georgia Medicaid, PBMs operate primarily through subcontracts with the four Care Management Organizations: Amerigroup Community Care, CareSource Georgia, Peach State Health Plan, and Wellpoint Georgia. The Georgia Department of Community Health retains certain direct regulatory and oversight roles including the statewide Preferred Drug List, the Pharmacy and Therapeutics Committee, the Drug Utilization Review Board, and DCH-CMO contract enforcement. The federal regulatory framework includes Section 1927 of the Social Security Act (the Medicaid Drug Rebate Program), the Consolidated Appropriations Act of 2023 (PBM transparency in managed care), Section 340B of the Public Health Service Act (the federal drug discount program), and CMS guidance curtailing spread pricing. State-level regulation is anchored in O.C.G.A. §33-64 and §33-64A (the Georgia Pharmacy Benefits Managers Act, administered by the Georgia Department of Insurance).

This guide translates the PBM framework for Georgia families and stakeholders. It covers how PBMs operate, the Medicaid Drug Rebate Program and rebate flow, the Preferred Drug List and prior authorization, step therapy and quantity limits, specialty pharmacy and mail-order operations, spread pricing and its curtailment, 340B and the anti-duplicate discount prohibition, Georgia state PBM regulation under O.C.G.A. §33-64, CAA 2023 transparency requirements, and how Georgia families navigate access barriers and appeals. Six worked examples illustrate how the framework operates for real Georgia families. A frequently asked questions section addresses the most common questions. A contact directory provides the phone numbers needed to file an appeal or escalate a complaint.

::callout{title="Key takeaways"}

• Pharmacy Benefit Managers (PBMs) are third-party administrators that process pharmacy claims, contract with pharmacy networks, manage formularies, administer prior authorization and step therapy, and negotiate manufacturer rebates. PBMs are not pharmacies.
• In Georgia Medicaid, PBMs operate through subcontracts with the four Care Management Organizations (Amerigroup, CareSource, Peach State, Wellpoint). DCH retains the statewide Preferred Drug List, Pharmacy and Therapeutics Committee, and Drug Utilization Review Board.
• Section 1927 of the Social Security Act (42 USC 1396r-8) establishes the Medicaid Drug Rebate Program. Manufacturers must enter into national rebate agreements to have their drugs covered by Medicaid. Rebate components include the Base Unit Rebate Amount, the inflation rebate, and confidential supplemental rebates.
• Section 1927(d) authorizes Drug Utilization Review and Preferred Drug Lists. Federal law requires timely prior authorization decisions; an emergency supply is available when PA cannot be completed in time.
• The Consolidated Appropriations Act of 2023 strengthened PBM transparency in Medicaid managed care, mandating CMO reporting of rebates received, pharmacy reimbursement amounts, PBM administrative fees, and any spread retained.
• Section 340B of the Public Health Service Act (42 USC 256b) provides deeply discounted drugs to FQHCs, Disproportionate Share Hospitals, Critical Access Hospitals, Ryan White grantees, and other covered entities. The Medicaid anti-duplicate discount prohibition prevents both a 340B discount and a Medicaid rebate on the same prescription.
• Spread pricing has been substantially curtailed by 2019 CMS guidance requiring spread to count as administrative cost in Medical Loss Ratio calculations, and by state-level pass-through PBM contract requirements.
• The Mental Health Parity and Addiction Equity Act of 2008 limits how restrictive utilization controls can be on mental health and substance use disorder drugs.
• Georgia's PBM regulation under O.C.G.A. §33-64 includes PBM licensure under the Department of Insurance, annual reporting, MAC appeal procedures for pharmacies, anti-discrimination provisions, and spread pricing transparency.
• The Georgia Preferred Drug List is the single statewide list applied uniformly across all four CMOs. Preferred drugs are covered without PA; non-preferred drugs require PA. The P&T Committee updates the PDL periodically through evidence-based clinical review.
• Prior authorization denials can be appealed through the CMO internal appeal process and ultimately through the State Fair Hearing process before the Office of State Administrative Hearings.
• Some manufacturers have restricted 340B contract pharmacy access since 2020, affecting how covered entities dispense 340B drugs through retail partnerships. Federal litigation and CMS oversight of these restrictions are ongoing. ::

The federal framework

By Brevy Care Team · Last verified May 12, 2026

Section 1927 and the Medicaid Drug Rebate Program

Section 1927 of the Social Security Act, codified at 42 USC 1396r-8, establishes the Medicaid Drug Rebate Program. The program operates as a condition of federal Medicaid coverage of outpatient drugs: a pharmaceutical manufacturer must enter into a national rebate agreement with the Department of Health and Human Services to have its covered outpatient drugs reimbursed under any state Medicaid program. The manufacturer pays rebates to the state on each prescription dispensed.

Rebate structure

The Medicaid Drug Rebate has three components:

• Base Unit Rebate Amount (URA): for innovator (brand-name) drugs, the URA is the greater of a statutory percentage of the Average Manufacturer Price (AMP) per unit or AMP minus Best Price per unit. For generic drugs, the URA is a statutory percentage of AMP per unit.
• Inflation rebate: an additional rebate amount triggered when the manufacturer's AMP increases faster than the Consumer Price Index for Urban Consumers (CPI-U). For brand drugs, the inflation rebate equals the cumulative amount by which AMP has risen above CPI-U since the launch of the drug, multiplied by units dispensed. Federal legislation has also added inflation rebates for generic drugs.
• Supplemental rebates: states can negotiate additional rebates with manufacturers in exchange for preferred placement on the state's Preferred Drug List. Supplemental rebates are confidential and negotiated individually with each manufacturer. Supplemental rebates can substantially exceed base rebates for high-cost drugs in competitive classes.

Rebate flow

Rebates flow to the state Medicaid agency from manufacturers. The state retains a portion (the state share, calculated based on the inverse of the Federal Medical Assistance Percentage), and the federal government claims a portion (the federal share). For a state with a 67 percent FMAP, for example, 33 percent of the rebate is state revenue and 67 percent is returned to the federal government.

In managed care, the CMO pays the pharmacy for the drug, and the state Medicaid agency collects the rebate from the manufacturer based on encounter data submitted by the CMO. Pre-2010, rebates were collected on fee-for-service only; the Affordable Care Act extended the Medicaid Drug Rebate Program to managed care arrangements.

CAA 2023 transparency

The Consolidated Appropriations Act of 2023 strengthened PBM transparency in Medicaid managed care, requiring CMOs and their PBM subcontractors to report rebate amounts received, dispensing fees paid, pharmacy reimbursement amounts, and other operational data.

42 CFR 447.500 through 447.520: Medicaid drug payment

The federal regulation at 42 CFR 447.500 through 447.520 governs Medicaid payment for outpatient drugs in fee-for-service arrangements. Key provisions include:

• Average Manufacturer Price (AMP): the price paid to the manufacturer by wholesalers for drugs distributed to retail community pharmacies, used in rebate calculations.
• National Average Drug Acquisition Cost (NADAC): a monthly survey-based pharmacy acquisition cost benchmark used by many states as the basis for ingredient cost reimbursement.
• Best Price: the lowest price available to any non-governmental purchaser, used in rebate calculations.
• Federal Upper Limits (FUL) for multi-source generic drugs based on a weighted average of AMPs.

Section 1927(d): Drug Utilization Review and Preferred Drug List authority

Section 1927(d) of the Social Security Act authorizes states to operate Drug Utilization Review (DUR) programs and Preferred Drug Lists.

The DUR program reviews prescriber and dispenser practices for clinical appropriateness, overutilization, underutilization, therapeutic duplication, drug-drug interactions, drug-disease interactions, and abuse or misuse. DUR has both prospective components (real-time alerts at the point of dispensing) and retrospective components (claims data analysis to identify patterns).

The Preferred Drug List allows states to designate preferred drugs within therapeutic classes and require prior authorization or step therapy for non-preferred drugs. Federal law requires state PDLs and PA programs to operate within specific protections:

• Timely prior authorization decisions within federal regulatory timeframes
• Emergency supply available when PA cannot be completed in time and the prescriber certifies medical necessity
• Prescriber notification of denials
• Beneficiary appeal rights through standard managed care appeal processes

Section 340B of the Public Health Service Act

The 340B Drug Pricing Program, authorized by Section 340B of the Public Health Service Act at 42 USC 256b, requires pharmaceutical manufacturers to provide outpatient drugs to eligible "covered entities" at deeply discounted "ceiling prices." Covered entities include Federally Qualified Health Centers, Disproportionate Share Hospitals, Critical Access Hospitals, Sole Community Hospitals, Rural Referral Centers, cancer hospitals, children's hospitals, Title X family planning clinics, Ryan White HIV/AIDS Program grantees, and tuberculosis clinics, among others.

340B and Medicaid: the anti-duplicate discount prohibition

A core Medicaid-340B interaction is the anti-duplicate discount prohibition. Medicaid receives a manufacturer rebate on covered outpatient drugs through the Medicaid Drug Rebate Program. Manufacturers do not pay both a 340B discount AND a Medicaid rebate on the same prescription. The covered entity, the manufacturer, and the Medicaid agency must coordinate to ensure that a given prescription receives only one of the two discounts.

States and covered entities use the Medicaid Exclusion File at HRSA to identify 340B prescriptions that should be excluded from Medicaid rebate calculations. The HRSA 340B Modifier "UD" is used on Medicaid claims to indicate 340B status.

Covered entities can choose to "carve in" (use 340B drugs for Medicaid patients and forgo Medicaid rebates) or "carve out" (do not use 340B drugs for Medicaid patients, allowing the state to collect rebates). The carve-in/carve-out decision can be different for managed care vs. fee-for-service and varies by entity and state.

340B contract pharmacy

The 340B program permits covered entities to dispense 340B drugs through "contract pharmacies" (third-party retail or specialty pharmacies under contract with the covered entity). Contract pharmacy arrangements expanded substantially after 2010 HRSA guidance permitting multiple contract pharmacy relationships per covered entity.

Beginning in 2020, several major pharmaceutical manufacturers (Eli Lilly, AstraZeneca, Sanofi, Novartis, Merck, and others) began restricting 340B contract pharmacy access, citing concerns about diversion and duplicate discounts. These restrictions have been the subject of substantial federal litigation, with covered entities and the federal government challenging manufacturer restrictions. State legislation has also addressed manufacturer 340B contract pharmacy restrictions.

Spread pricing curtailment

Spread pricing is the practice by which a PBM bills the plan (state Medicaid agency or CMO) more for a drug than it pays the dispensing pharmacy, retaining the difference as PBM revenue.

Example: PBM pays pharmacy $50 for a prescription. PBM bills the CMO $70 for the prescription. PBM retains $20 as "spread" without clear disclosure of the gap.

The 2018 Ohio State Auditor's report on Ohio Medicaid spread pricing was a landmark investigation. The report found that PBMs operating in Ohio Medicaid had earned substantial spread over a 12-month period. The report was followed by similar audits in many other states.

CMS responded in 2019 with guidance clarifying that PBM spread in Medicaid managed care must be reflected in Medical Loss Ratio calculations, effectively curtailing the practice because PBM spread retained must count as administrative cost rather than medical cost. Many states subsequently moved to "pass-through" PBM contracts where the PBM is paid an explicit administrative fee and the actual pharmacy reimbursement amount is passed through to the plan transparently.

The CAA 2023 strengthened transparency requirements that effectively eliminate the practical value of any remaining spread pricing in Medicaid managed care.

Mental Health Parity Act and pharmacy

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that mental health and substance use disorder benefits be no more restrictive than medical/surgical benefits in scope, frequency, duration, and treatment limitations. MHPAEA applies to Medicaid managed care under CMS implementing rules.

Pharmacy parity means that utilization controls on mental health and substance use disorder drugs (antidepressants, antipsychotics, anti-anxiety medications, mood stabilizers, stimulants for ADHD, buprenorphine for opioid use disorder, methadone for opioid use disorder, naltrexone) cannot be more restrictive than comparable controls on medical/surgical drugs. Step therapy, prior authorization, formulary tiering, and quantity limits must comply with parity analysis.

Federal anti-kickback statute

The federal anti-kickback statute (42 USC 1320a-7b(b)) prohibits remuneration in exchange for referrals of items or services payable by federal health care programs. PBM-manufacturer rebate arrangements have historically operated under a safe harbor. The HHS Office of Inspector General has issued advisory opinions and guidance on PBM rebate arrangements. The 2020 HHS rebate rule (later modified) attempted to address rebate transparency concerns through anti-kickback safe harbor changes.

Inflation Reduction Act 2022 and Medicaid

The Inflation Reduction Act of 2022 (PL 117-169) primarily addresses Medicare drug pricing (Medicare Part D redesign, Medicare drug negotiation, Medicare inflation rebates). Medicaid spillover effects include modest changes to AMP definitions and best price calculations. The Medicaid Drug Rebate Program remains the dominant federal mechanism for Medicaid drug pricing.

The Georgia framework

O.C.G.A. §33-64: Georgia PBM regulation

O.C.G.A. §33-64 establishes the Georgia Pharmacy Benefits Managers Act, subjecting PBMs operating in Georgia to licensure, reporting, and operational requirements under the Georgia Department of Insurance. Provisions include:

• PBM licensure requirement: every PBM operating in Georgia must hold a Georgia license issued by the Department of Insurance.
• Annual reporting: PBMs must submit annual reports on operations including rebate amounts, dispensing fees paid, pharmacy reimbursement rates, and other data.
• Rebate transparency: PBMs must disclose rebate practices and rebate retention.
• Network contracting: PBMs must comply with network contracting fairness rules including anti-discrimination provisions.
• MAC (Maximum Allowable Cost) appeal procedures: PBMs must operate transparent MAC pricing for generic drugs and provide pharmacies with appeal procedures for MAC pricing disputes.
• Anti-discrimination: PBMs cannot discriminate against any willing provider that meets network participation criteria.
• Cost-pass-through requirements for certain plans.

O.C.G.A. §33-64A adds enhanced transparency requirements specifically addressing spread pricing, rebate retention, and operational disclosure.

O.C.G.A. §49-4-191 and pharmacy claim payment

O.C.G.A. §49-4-191 addresses pharmacy claim payment to pharmacies in Medicaid including dispensing fee requirements and timing of payments. Pharmacies have specific protections regarding claim adjudication timeliness and payment terms.

Georgia State Board of Pharmacy

The Georgia State Board of Pharmacy, operating under Title 26 of the Georgia Code (O.C.G.A. §26-4 and related provisions), regulates pharmacists, pharmacy interns, and pharmacy operations in Georgia. The Board licenses pharmacies, investigates complaints about pharmacy practice, and disciplines pharmacy practice violations. The Board's authority is separate from but coordinated with the Department of Insurance's PBM regulation.

DCH Pharmacy Services

DCH Pharmacy Services administers the Medicaid pharmacy benefit at the state level. Key DCH functions include:

• Preferred Drug List (PDL) development and maintenance: the statewide Georgia Medicaid PDL designates preferred and non-preferred drugs across therapeutic classes.
• Drug Utilization Review (DUR) Board: clinical and operational oversight of pharmacy utilization patterns.
• Pharmacy and Therapeutics (P&T) Committee: evidence-based clinical review of drugs and classes for PDL designation.
• Pharmacy provider enrollment: enrollment of Georgia pharmacies in the Medicaid program.
• Drug rebate collection and reconciliation: state-level operations to collect and account for Medicaid Drug Rebate Program rebates.
• PBM oversight under DCH-CMO contracts: enforcement of pharmacy provisions in CMO contracts.
• Pharmacy provider manual maintenance: official guidance for pharmacy providers participating in Georgia Medicaid.

The DCH PDL is the single statewide list applied uniformly across the four CMOs. The PDL is updated periodically through the P&T Committee process.

Pharmacy and Therapeutics (P&T) Committee

The DCH P&T Committee includes physicians, pharmacists, and other clinical experts who review drug classes, evaluate clinical evidence, consider cost-effectiveness, and recommend preferred drug designations. P&T Committee meetings include public comment periods. The Committee's recommendations are reviewed by DCH leadership and finalized through formal PDL updates.

Drug Utilization Review (DUR) Board

The DCH DUR Board reviews patterns of prescribing and dispensing, identifies issues, and recommends interventions. The DUR Board issues retrospective reviews (analyzing claims data after the fact) and supports prospective DUR (real-time alerts at the point of dispensing). DUR addresses opioid prescribing patterns, psychotropic prescribing in children, polypharmacy in elderly populations, and other clinically important utilization issues.

DCH-CMO contracts and PBM subcontracting

DCH-CMO contracts include detailed pharmacy provisions. The four CMOs typically subcontract pharmacy benefit management to large national PBMs:

• Amerigroup: pharmacy operations through Elevance Health's CarelonRx or comparable subcontracted PBM
• CareSource Georgia: pharmacy operations historically through CVS Caremark or comparable subcontracted PBM
• Peach State Health Plan: pharmacy operations through Centene's Envolve Pharmacy Solutions or comparable subcontracted PBM
• Wellpoint Georgia: pharmacy operations through Elevance Health's CarelonRx (similar to Amerigroup given common Elevance Health corporate parent)

The specific PBM arrangements can change as CMO corporate structures evolve and as CMOs rebid PBM contracts. The DCH-CMO contract requires the CMO to ensure PBM compliance with state and federal requirements regardless of subcontracting.

Historic FFS PBM and transition

Georgia DCH historically contracted directly with a single PBM for the fee-for-service Medicaid population. As Georgia Medicaid moved to predominantly managed care, the FFS PBM role has been substantially reduced. Most Medicaid prescriptions in Georgia now flow through CMO-PBM subcontracts. A residual FFS pharmacy population includes nursing facility residents (carved out of Georgia Families), certain dual eligibles, and others not enrolled in managed care.

How the PBM operates day-to-day

The PBM functions across multiple operational dimensions.

Formulary and PDL management

The PBM maintains the operational formulary that implements DCH's statewide Preferred Drug List. Drugs are categorized as preferred (covered without PA within standard utilization rules), non-preferred (requiring PA), or excluded (not covered, with limited exception pathways).

For a CMO using DCH's statewide PDL, the PBM applies the PDL designations uniformly across all members and adds any additional CMO-specific or PBM-specific utilization controls within DCH-approved limits. Mental Health Parity Act requirements limit utilization controls on mental health and substance use disorder drugs.

Prior authorization

Non-preferred drugs and drugs subject to step therapy require prior authorization. The prescriber submits a PA request to the PBM with clinical documentation supporting the request: diagnosis, prior treatment history, contraindications to preferred alternatives, clinical rationale for the requested drug, and supporting laboratory or imaging findings.

Federal law requires PA decisions within a specified timeframe after receipt of the request. Routine PAs are reviewed by pharmacists; complex or denied PAs typically receive medical director review.

If the PA is approved, the pharmacy can dispense and process the claim. If the PA is denied, the prescriber and member can appeal through the CMO appeal process.

Emergency supply when PA cannot be completed in time

If the prescriber certifies that immediate dispensing is medically necessary and PA cannot be completed in time, the pharmacy must dispense an emergency supply at standard reimbursement. The PA process continues in parallel.

Step therapy

Step therapy requires the patient to try preferred drugs in a class before non-preferred drugs are authorized. Step therapy is common for:

• Antidepressants: preferred SSRI first, then escalation to non-preferred SNRI or atypical agents
• Proton pump inhibitors: preferred generic first
• Inhaled corticosteroids for asthma: preferred combination first
• Diabetes drugs: preferred metformin and sulfonylurea before non-preferred GLP-1 agonists
• Statins: preferred generic statin first

Step therapy exceptions can be granted for clinical reasons including prior failure of preferred drugs, contraindications, drug-drug interactions, or specific patient circumstances.

Mental Health Parity Act analysis applies to step therapy on psychiatric drugs.

Quantity limits

Quantity limits cap the number of units that can be dispensed per fill or per time period. Quantity limits address drug class-specific concerns:

• Stimulants for ADHD (methylphenidate, amphetamines): limited monthly supply, Schedule II controlled substance restrictions
• Opioids: limited daily morphine milligram equivalents under state and federal opioid prescribing policies
• Benzodiazepines: controlled substance restrictions
• High-cost specialty drugs: limited per-fill quantities
• Drugs with abuse potential: tighter quantity restrictions

Pharmacy network contracting

The PBM contracts with retail, specialty, mail-order, and long-term care pharmacies to form the network. Pharmacy contracts specify:

• Ingredient cost reimbursement methodology (typically NADAC or actual acquisition cost plus a percentage)
• Dispensing fees
• Performance metrics (claim adjudication timeliness, complaint resolution, audit compliance)
• Compliance requirements
• Maximum Allowable Cost (MAC) pricing for generics

In Georgia, pharmacy network contracts must comply with O.C.G.A. §33-64 anti-discrimination provisions, MAC appeal procedures, and other state law requirements.

Specialty pharmacy management

Specialty drugs (high-cost, often injectable or infused drugs for chronic complex conditions including multiple sclerosis, rheumatoid arthritis, cancer, HIV, hepatitis C, rare diseases, complex pediatric conditions) are typically dispensed through designated specialty pharmacies rather than general retail. Specialty pharmacies provide clinical management, adherence support, patient education, refrigerated shipping, and coordination with prescribers.

PBMs typically own or contract with specialty pharmacies for these drugs. CVS Caremark owns CVS Specialty. Express Scripts owns Accredo. OptumRx owns BriovaRx. These vertical relationships have raised regulatory concerns about competition and member choice.

Mail-order pharmacy

Mail-order pharmacy operations dispense 30 to 90-day supplies of maintenance medications by mail. Mail-order is voluntary for most members but PBMs may incentivize use through lower copayments. For long-term care patients, mail-order or LTC pharmacy is typically default.

Claims processing

The PBM processes pharmacy claims in real time at the point of sale. Claims include:

• Patient identifier
• Prescriber identifier (DEA number for controlled substances)
• Drug National Drug Code (NDC)
• Quantity and days supply
• Origin code (new vs. refill)
• Diagnosis code in some cases
• 340B modifier if applicable

The PBM checks eligibility, formulary status, prior authorization status, step therapy, quantity limits, drug-drug interactions (prospective DUR), age and gender restrictions, and other rules. Approved claims generate a payment to the pharmacy. Denied claims generate a rejection message with reason codes.

Rebate negotiation

The PBM (or CMO directly, depending on the contracting structure) negotiates supplemental rebates with manufacturers in exchange for preferred placement on the formulary. Supplemental rebate negotiations are confidential. Rebate dollars flow back to the state and federal government in fee-for-service and (since the ACA) in managed care arrangements.

340B coordination

For prescriptions written by 340B-eligible providers (FQHC physicians, DSH hospital outpatient providers, Ryan White grantees), the PBM must coordinate with 340B operations to ensure correct billing and anti-duplicate discount compliance. The pharmacy bills the PBM using appropriate modifiers (UD modifier in HRSA guidance). The state Medicaid agency excludes the prescription from the Medicaid Drug Rebate calculation per the Medicaid Exclusion File entry for the covered entity.

Spread pricing in detail

Spread pricing has been one of the most controversial PBM practices.

The Ohio State Auditor's 2018 report on Ohio Medicaid spread pricing investigated PBM practices in Ohio Medicaid managed care. The report found that PBMs operating in Ohio Medicaid had earned substantial spread over a 12-month period. PBMs were billing the state at higher rates than they were paying pharmacies, and retaining the difference without clear disclosure.

The Ohio findings catalyzed similar investigations in many other states. In 2019, CMS issued guidance clarifying that PBM spread in Medicaid managed care must be reflected in Medical Loss Ratio calculations. Under federal Medicaid managed care Medical Loss Ratio (MLR) rules, a managed care plan must spend the required portion of capitation on medical care; the remainder can be administrative cost and profit. PBM spread cannot be counted as medical cost because the dollars are not actually paid to providers of care; they are retained by the PBM as administrative revenue. Treating spread as administrative cost effectively caps the practice within the administrative cost ceiling, dramatically reducing its profitability.

Many states subsequently moved to "pass-through" PBM contracts. Under a pass-through arrangement, the PBM is paid an explicit administrative fee (typically a per-claim or per-member-per-month amount) and the actual pharmacy reimbursement is passed through to the plan transparently. The PBM cannot retain any difference between what it bills the plan and what it pays the pharmacy.

The CAA 2023 strengthened transparency requirements. CMOs must report rebate amounts received, pharmacy reimbursement amounts paid, PBM administrative fees, and any spread retained. The transparency disclosure effectively eliminates the value of any remaining spread arrangements, as any spread retained will be visible to CMS, state Medicaid agencies, and the public.

Georgia DCH-CMO contracts have been updated over time to require transparency in PBM arrangements. CAA 2023 transparency requirements further constrain spread pricing in Georgia Medicaid managed care.

The prior authorization process step-by-step

Prior authorization is one of the most consequential PBM tools and one of the most common sources of member complaints and appeals. The process unfolds as follows.

Step 1: Prescription written

The prescriber writes a prescription for a drug that requires PA. The prescriber may or may not know in advance that the drug requires PA. Many electronic health record systems integrate with PBM databases to alert prescribers about PA requirements at the point of prescribing, but coverage is imperfect, especially for less common drugs.

Step 2: Pharmacy submits claim

The patient brings the prescription to the pharmacy. The pharmacy submits the claim electronically. The PBM rejects the claim with a "PA required" message and reason code.

Step 3: PA request submitted

The pharmacy or prescriber initiates the PA request. The prescriber submits clinical documentation to the PBM including:

• Diagnosis (typically with ICD-10 code)
• Prior treatment history with preferred alternatives (drugs tried, durations, outcomes)
• Contraindications to preferred alternatives (drug-drug interactions, allergies, side effects)
• Clinical rationale for the requested drug
• Supporting laboratory or imaging findings if relevant
• Statement of medical necessity

PA submissions are made through PBM web portals, fax, or electronic prior authorization (ePA) systems integrated with EHRs.

Step 4: PBM clinical review

The PBM reviews the request against clinical criteria. Criteria are typically based on:

• Evidence-based clinical guidelines from professional societies (American Diabetes Association for diabetes drugs, American Psychiatric Association for psychiatric drugs, American Heart Association for cardiovascular drugs, and others)
• FDA labeling (approved indications, contraindications, warnings)
• The Georgia Preferred Drug List with class-specific criteria
• Cost-effectiveness considerations within DCH and CMO operational parameters

Routine reviews are conducted by pharmacists who are typically registered pharmacists with clinical training. Complex reviews or denied PAs typically receive medical director review by a physician.

Step 5: PA decision within 24 hours

The PBM issues an approval or denial within the federally required timeframe.

• Approval: the PBM updates its system to recognize the PA. The pharmacy can submit the claim and receive payment. The patient can pick up the prescription. Approval is typically for a fixed period (e.g., 90 days, 6 months, 1 year) after which renewal PA may be required.
• Denial: the PBM issues a Notice of Adverse Benefit Determination to the member and prescriber explaining the denial reason and appeal rights.

Step 6: Emergency supply if needed

If the prescriber certifies that immediate dispensing is medically necessary and PA cannot be completed in time, the pharmacy must dispense an emergency supply at standard reimbursement. The PA process continues in parallel.

Step 7: Appeal if denied

If the PA is denied, the member and prescriber can appeal through the CMO internal appeal process. The appeal procedure follows the standard managed care framework under 42 CFR 438.402 through 438.424:

• Filing window: within the timeframe specified in the Notice of Adverse Benefit Determination
• Filing method: oral or written, with the CMO or designated entity
• Standard resolution: within regulatory timeframes
• Expedited resolution: available if standard timeframes could jeopardize health
• Aid paid pending: continuation of previously authorized services during appeal if requested promptly
• Clinical peer review: medical necessity decisions reviewed by clinical peer not involved in original decision

If the internal appeal upholds the denial, the member can request a State Fair Hearing before an Administrative Law Judge of the Georgia Office of State Administrative Hearings (OSAH). The State Fair Hearing is an independent administrative review process. Free legal help is available from Georgia Legal Services Program or Atlanta Legal Aid Society.

340B in Georgia Medicaid context

Georgia FQHCs (Mercy Care Atlanta, Whitefoord, Curtis V. Cooper Savannah, Albany Area Primary Health Care, and others) operate 340B programs and dispense 340B drugs through in-house pharmacies and through contract pharmacy arrangements with retail pharmacies. Georgia Disproportionate Share Hospitals (Grady Health System, Augusta University Medical Center, and others), Critical Access Hospitals, Ryan White grantees, and Title X family planning clinics also operate 340B programs.

For Medicaid patients, 340B covered entities can:

• Carve out: dispense non-340B drugs for Medicaid patients, allowing the state to collect Medicaid rebates. The state Medicaid Drug Rebate Program calculations include these prescriptions.
• Carve in: dispense 340B drugs for Medicaid patients, foregoing Medicaid rebates. The state excludes these prescriptions from rebate calculations per the Medicaid Exclusion File.

The carve-in/carve-out decision can be different for managed care vs. fee-for-service patients. Georgia DCH maintains the Medicaid Exclusion File entries identifying carved-in 340B entities. The CMO PBM must recognize 340B claims correctly to avoid duplicate discount violations.

Pharmacies dispensing 340B drugs apply the HRSA 340B "UD" modifier on Medicaid claims. The PBM must recognize the modifier and process the claim without seeking duplicate discounts from manufacturers. Failure to comply can result in manufacturer disputes, federal HRSA enforcement, and potential False Claims Act exposure.

Manufacturer restrictions on 340B contract pharmacy

Beginning in 2020, several major pharmaceutical manufacturers (Eli Lilly, AstraZeneca, Sanofi, Novartis, Merck, Boehringer Ingelheim, AbbVie, and others) began restricting 340B contract pharmacy access. The restrictions vary by manufacturer:

• Some manufacturers refuse to ship 340B drugs to any contract pharmacy
• Some manufacturers allow shipment to only one contract pharmacy per covered entity
• Some manufacturers require covered entities to share patient-level claims data with the manufacturer
• Some manufacturers exempt rural CAHs or certain narrow categories

These restrictions have substantially disrupted covered entity contract pharmacy operations. HRSA has taken enforcement action against some manufacturers. Federal courts have reached varying conclusions, with the Third Circuit, D.C. Circuit, and other circuits ruling on different manufacturer-specific cases. The legal landscape continues to evolve.

State legislation in many states (including bills introduced or considered in Georgia) has addressed manufacturer 340B contract pharmacy restrictions, requiring manufacturers to provide drugs to contract pharmacies as a condition of state-level activities. The interaction between state legislation and federal preemption analysis is the subject of ongoing litigation.

Georgia covered entities affected by manufacturer restrictions have responded by:

• Dispensing more 340B drugs through in-house pharmacies
• Consolidating contract pharmacy relationships
• Engaging in federal advocacy and litigation
• Working with state policymakers on legislative responses

CAA 2023 PBM transparency

The Consolidated Appropriations Act of 2023 strengthened PBM transparency requirements in Medicaid managed care, requiring CMOs to:

• Report rebate amounts received from manufacturers
• Report pharmacy reimbursement amounts paid (ingredient cost plus dispensing fee)
• Report PBM administrative fees and any spread retained
• Disclose 340B drug status of claims
• Report specialty pharmacy operations
• Provide pharmacy-level data on patient out-of-pocket costs
• Submit data to CMS for transparency analyses

Georgia DCH and the four CMOs are operating under the new transparency framework, with quarterly and annual reporting flowing to CMS for federal oversight. The transparency framework enables policymakers, advocates, and the public to assess PBM practices in Medicaid managed care with substantially more visibility than has been historically available.

Worked examples: how Georgia families experience PBM operations

Marcus, 45, Atlanta, T2DM, non-preferred insulin and switch to preferred

Marcus has type 2 diabetes managed with insulin glargine. His endocrinologist prescribes Lantus brand insulin glargine. Marcus is enrolled in Amerigroup. The Amerigroup PBM rejects the claim at the pharmacy with a "PA required" rejection because Lantus is non-preferred on the DCH PDL (Basaglar, the biosimilar insulin glargine, is preferred as the lower-cost alternative).

The pharmacy provides an emergency supply of Lantus while the prescriber submits a PA request. The endocrinologist evaluates whether Marcus needs Lantus specifically or whether Basaglar would be appropriate. For most patients with type 2 diabetes, Basaglar is clinically equivalent to Lantus. The endocrinologist switches the prescription to Basaglar. Marcus continues his insulin therapy with no clinical interruption.

If Marcus had a clinical reason for needing Lantus specifically (allergy to a Basaglar excipient, prior treatment failure on Basaglar, or other documented contraindication), the endocrinologist would submit a PA request with clinical documentation. The PBM would review for medical necessity. If approved, Lantus would be dispensed. If denied, the endocrinologist could appeal through the CMO appeal process.

Aisha, 28, Macon, depression, step therapy through SSRIs

Aisha is diagnosed with major depression. Her psychiatrist prescribes Cymbalta (duloxetine, an SNRI). Aisha is enrolled in Peach State. The Peach State PBM rejects the claim because Cymbalta is subject to step therapy: the member must try at least one preferred SSRI first.

Aisha's psychiatrist documents that Aisha previously tried sertraline (a preferred SSRI) for 8 weeks at therapeutic dose with inadequate response and significant nausea. The psychiatrist submits a PA request with this clinical history including dates of treatment, doses tried, and clinical assessment of outcome. The PBM approves Cymbalta based on the documented prior trial.

If Aisha had not previously tried an SSRI, the psychiatrist would either start her on sertraline (or another preferred SSRI) or submit a PA for Cymbalta based on a clinical contraindication or other rationale. Mental Health Parity Act requirements limit how restrictive step therapy can be for psychiatric drugs relative to medical/surgical drugs, so the PBM cannot apply more restrictive criteria to antidepressants than to comparable medical drug classes.

If the PA is denied, Aisha can appeal through Peach State and ultimately through the State Fair Hearing. Free legal help from Georgia Legal Services Program is available.

Diana, 72, Albany, Alzheimer's, specialty drug PA

Diana is diagnosed with mild Alzheimer's disease. Her neurologist discusses treatment options including donepezil (preferred, generic) and a newer monoclonal antibody therapy (specialty drug, very high cost, requires biomarker confirmation of amyloid). They decide to start with donepezil.

Donepezil is preferred on the DCH PDL and no PA is required. The pharmacy dispenses donepezil with a standard $1 copayment (within Section 1916 Medicaid cost-sharing limits).

If Diana progresses and her neurologist considers a specialty monoclonal antibody, the prescription would require extensive PA documentation including disease staging (Clinical Dementia Rating, Mini Mental State Examination), MRI findings (excluding contraindications like superficial siderosis), biomarker testing (amyloid PET imaging or CSF biomarkers), clinical assessment, and treatment plan including infusion site coordination. The specialty pharmacy would coordinate dispensing through infusion at an in-network infusion center. PA denial could be appealed if clinical criteria are met.

Tyrell, 19, Atlanta, HIV, 340B FQHC contract pharmacy

Tyrell is HIV positive and receives care at Mercy Care, an Atlanta FQHC. His prescriptions for antiretroviral therapy (ART) are dispensed through Mercy Care's 340B contract pharmacy arrangement with a local retail pharmacy.

Tyrell's Medicaid claim is submitted with the HRSA 340B "UD" modifier indicating 340B status. The CMO PBM recognizes the modifier and pays the pharmacy at the negotiated rate. The state Medicaid agency excludes this prescription from the Medicaid Drug Rebate Program calculation per the Medicaid Exclusion File entry for Mercy Care.

The 340B discounted price for ART drugs is substantially below market price. Mercy Care retains the difference between the 340B price and the reimbursement amount, using the savings to fund other clinical operations, expand HIV care, and subsidize uninsured patient care.

If a manufacturer restriction on 340B contract pharmacy access affects Tyrell's specific ART regimen (some manufacturers have applied restrictions to specific drug classes), Mercy Care may need to dispense Tyrell's prescription through its in-house pharmacy rather than through the contract pharmacy. Mercy Care has invested in expanded in-house pharmacy capacity in response to manufacturer restrictions.

Jamil, 12, Savannah, ADHD, quantity limit on stimulants

Jamil has ADHD and is prescribed methylphenidate extended-release. His Medicaid coverage is through CareSource Georgia. Methylphenidate is a Schedule II controlled substance subject to quantity limits. The CareSource PBM applies a 30-day supply limit per fill, consistent with DEA rules for Schedule II controlled substances.

Jamil's psychiatrist writes a 30-day prescription. The PBM approves the claim and the pharmacy dispenses. At the end of 30 days, the psychiatrist must write a new prescription (DEA rules prohibit refills on Schedule II controlled substances).

If Jamil's clinical situation requires a higher dose than standard FDA-approved doses (sometimes occurs with adolescents transitioning from pediatric to adult doses), the prescriber submits a PA request with clinical rationale. PA denial can be appealed.

Sarah, 38, rural Augusta area, MS, specialty pharmacy + mail order + PA + appeal

Sarah has multiple sclerosis treated with a specialty disease-modifying therapy (ocrelizumab, an infused monoclonal antibody). Her neurologist prescribes the therapy and the CMO PBM requires PA, specialty pharmacy dispensing, and infusion at an in-network infusion center.

Sarah's CMO PBM initially denies the PA, citing a step therapy requirement that Sarah try a less expensive preferred therapy first. Sarah's neurologist documents that Sarah previously tried glatiramer acetate for 18 months with disease progression (documented by serial MRI showing new T2 lesions and serial EDSS scores showing clinical worsening) and that her disease severity warrants escalation to a high-efficacy therapy. The neurologist submits an appeal with detailed clinical documentation including MRI reports, EDSS scores, relapse documentation, and clinical assessment.

The CMO appeals process resolves within regulatory timeframes for standard and expedited review (Sarah's neurologist requests expedited review based on disease activity). If the expedited appeal is denied, Sarah can request a State Fair Hearing. Aid paid pending may apply if Sarah was previously receiving the therapy.

If the appeal is upheld, the specialty pharmacy coordinates dispensing the drug for infusion at the in-network center. Sarah's care continues with the high-efficacy therapy.

Practical guidance

How to get a prescription filled when PA is required

If your pharmacy tells you that your prescription needs prior authorization:

1. Ask the pharmacy to submit the PA request immediately, or contact your prescriber to do so.
2. Ask the pharmacy about an emergency supply if your prescriber certifies medical necessity for immediate dispensing.
3. Have your prescriber submit clinical documentation including diagnosis, prior treatment history, and clinical rationale.
4. Federal law requires the PBM to issue a decision within a specified timeframe.
5. If approved, return to the pharmacy to fill the prescription.
6. If denied, you can appeal. Contact your CMO member services line and request the appeal procedure.

How to appeal a PA denial

If your PA is denied:

1. You will receive a Notice of Adverse Benefit Determination from your CMO. Read it carefully and note the appeal deadline listed in the notice.
2. Contact your CMO member services line to start the appeal (call the number on your member ID card or look up your CMO's current pharmacy member services number).
3. Ask your prescriber to submit additional clinical documentation supporting medical necessity.
4. Request expedited review if standard timeframes could harm your health.
5. Request aid paid pending if you were previously receiving the medication and file promptly.
6. If the CMO appeal is denied, file a State Fair Hearing request with the Office of State Administrative Hearings (OSAH).
7. Consider free legal help from Georgia Legal Services Program or Atlanta Legal Aid Society.

How to use 340B pharmacy if you receive care at an FQHC

If you receive care at a Georgia FQHC (Mercy Care, Whitefoord, Curtis V. Cooper, Albany Area, or others), ask whether your prescriptions can be filled through the FQHC's 340B pharmacy. The 340B pharmacy can dispense your medications at deeply discounted prices, which the FQHC uses to subsidize other clinical operations. Some manufacturer restrictions on contract pharmacy may apply to specific drugs. Discuss with your FQHC's pharmacy team.

How to navigate specialty drugs

If you are prescribed a specialty drug (high-cost injectable, infused, or oral specialty medication):

1. Your prescriber will typically initiate PA and coordinate with the CMO's designated specialty pharmacy.
2. The specialty pharmacy will contact you to coordinate dispensing, including any required refrigeration and shipping.
3. The specialty pharmacy will provide clinical management, adherence support, and patient education.
4. For infused drugs, you will receive the drug at an in-network infusion center.
5. If your specialty drug is denied, follow the appeal procedure above.

How to use brevy.com resources

The brevy.com Georgia Medicaid section provides additional guides covering prescription drug coverage, the four CMOs, FQHCs and 340B, behavioral health coverage, appeals and fair hearings, and many other related topics. The guides are written for Georgia families navigating these complex systems.

Frequently asked questions

::accordion ::accordion-item{title="What is a PBM and how is it different from a pharmacy?"} A Pharmacy Benefit Manager (PBM) is a third-party administrator that manages the prescription drug benefit on behalf of a health plan (state Medicaid agency or CMO in Medicaid managed care). The PBM processes claims, contracts with pharmacy networks, manages the formulary, administers prior authorization and step therapy, and negotiates manufacturer rebates. A pharmacy is the brick-and-mortar (or mail-order) entity that dispenses drugs. The PBM contracts with pharmacies to form the network. Some large PBMs own pharmacies (specialty, mail-order, retail), creating vertical integration that has raised regulatory concerns. ::

::accordion-item{title="Who is my CMO's PBM?"} In Georgia Medicaid, PBMs operate through subcontracts with the four CMOs. The specific PBM arrangements can change as CMO corporate structures evolve. Approximate current arrangements: Amerigroup uses CarelonRx (Elevance Health pharmacy operations); CareSource Georgia historically uses CVS Caremark; Peach State Health Plan uses Centene's Envolve Pharmacy Solutions; Wellpoint Georgia uses CarelonRx (similar to Amerigroup, given common Elevance Health parent). Confirm the current arrangement by contacting your CMO member services line. ::

::accordion-item{title="What is the Preferred Drug List (PDL)?"} The Preferred Drug List is the list of drugs designated as preferred or non-preferred across therapeutic classes by the Georgia Department of Community Health. The PDL is the same across all four Georgia Families CMOs. Preferred drugs are covered without prior authorization. Non-preferred drugs require prior authorization. The PDL is developed and updated by DCH's Pharmacy and Therapeutics Committee through evidence-based clinical review. ::

::accordion-item{title="What is prior authorization and how long does it take?"} Prior authorization (PA) is a process by which the PBM reviews and approves coverage of a specific drug for a specific patient before the drug can be dispensed. PA is required for non-preferred drugs, drugs subject to step therapy, drugs with quantity limits exceeded, and drugs with age or diagnosis restrictions. Federal law requires PA decisions within a specified timeframe after receipt of the request. If PA cannot be completed in time, federal law requires an emergency supply when the prescriber certifies medical necessity. ::

::accordion-item{title="What is step therapy?"} Step therapy requires the patient to try preferred drugs in a class before non-preferred drugs are authorized. For example, in the antidepressant class, the patient may need to try a preferred SSRI first before a non-preferred SNRI is authorized. Step therapy can be overridden for clinical reasons including prior treatment failure, contraindications, or drug-drug interactions. Mental Health Parity Act requirements limit how restrictive step therapy can be for psychiatric drugs. ::

::accordion-item{title="What is a quantity limit?"} A quantity limit caps the number of units that can be dispensed per fill or per time period. Quantity limits are common for controlled substances (stimulants, opioids, benzodiazepines), high-cost specialty drugs, and drugs with abuse potential. Higher quantities can be authorized through PA with clinical documentation of necessity. ::

::accordion-item{title="What is the emergency supply when PA cannot be completed in time?"} If a prescriber certifies that immediate dispensing is medically necessary and prior authorization cannot be completed in time, federal law requires the pharmacy to dispense an emergency supply at standard reimbursement. The PA process continues in parallel. The emergency supply ensures that patients do not lose access to needed medications while administrative processes are completed. ::

::accordion-item{title="What is the Medicaid Drug Rebate Program?"} The Medicaid Drug Rebate Program, authorized by Section 1927 of the Social Security Act (42 USC 1396r-8), requires pharmaceutical manufacturers to pay rebates to state Medicaid agencies on outpatient drugs covered by Medicaid. The rebate has a base component (a statutory percentage of AMP for brand and generic drugs), an inflation component, and a supplemental component negotiated by individual states. Rebates flow back to state and federal government. The rebate program is a major source of Medicaid drug cost savings. ::

::accordion-item{title="What is Section 340B and how does it interact with Medicaid?"} Section 340B of the Public Health Service Act (42 USC 256b) provides deeply discounted drugs to FQHCs, Disproportionate Share Hospitals, Critical Access Hospitals, Ryan White grantees, and other covered entities. The anti-duplicate discount prohibition prevents both a 340B discount and a Medicaid rebate on the same prescription. Covered entities can "carve in" (use 340B drugs for Medicaid patients) or "carve out" (avoid using 340B drugs for Medicaid patients). The HRSA 340B "UD" modifier identifies 340B claims for proper handling. ::

::accordion-item{title="What is spread pricing and has it been eliminated?"} Spread pricing is the practice of a PBM billing the plan more for a drug than the PBM pays the pharmacy, retaining the difference. Spread pricing was historically common in Medicaid managed care. CMS guidance in 2019 required spread to count as administrative cost in Medical Loss Ratio calculations, effectively curtailing the practice. The CAA 2023 strengthened transparency requirements that further constrain spread pricing. Many states use pass-through PBM contracts where the PBM is paid an explicit administrative fee and the actual pharmacy reimbursement is passed through transparently. ::

::accordion-item{title="What is CAA 2023 PBM transparency?"} The Consolidated Appropriations Act of 2023 strengthened PBM transparency in Medicaid managed care, requiring CMOs to report rebate amounts received, pharmacy reimbursement amounts paid, PBM administrative fees, any spread retained, 340B drug status, specialty pharmacy operations, and pharmacy-level data on patient out-of-pocket costs. ::

::accordion-item{title="Can I appeal a PA denial?"} Yes. Appeal through your CMO internal appeal process within the timeframe stated in your Notice of Adverse Benefit Determination. The CMO must resolve standard appeals within regulatory timeframes; expedited appeals (when standard timeframes could jeopardize health) are resolved faster. Request aid paid pending if you were previously receiving the medication and file promptly. If the CMO appeal is denied, request a State Fair Hearing with the Georgia Office of State Administrative Hearings (OSAH). Free legal help is available from Georgia Legal Services Program. ::

::accordion-item{title="What if my pharmacy refuses to provide my medication?"} Pharmacies are required to fill valid prescriptions for medications in their network arrangement. If your pharmacy refuses to fill a covered prescription, ask for the specific reason (typically a PA rejection from the PBM). If the pharmacy is refusing for reasons unrelated to coverage (e.g., out of stock, supplier issues), ask whether the pharmacy can order the medication or transfer the prescription to another network pharmacy. For systemic pharmacy network issues, file a grievance with your CMO. For pharmacy practice concerns, contact the Georgia State Board of Pharmacy. ::

::accordion-item{title="Are PBMs regulated in Georgia?"} Yes. O.C.G.A. §33-64 establishes the Georgia Pharmacy Benefits Managers Act, subjecting PBMs operating in Georgia to licensure by the Georgia Department of Insurance, annual reporting, rebate transparency, network contracting fairness, MAC appeal procedures, and anti-discrimination requirements. O.C.G.A. §33-64A adds enhanced transparency requirements addressing spread pricing and rebate retention. PBM complaints can be filed with the Georgia Department of Insurance. :: ::

Contact directory

::cta{title="Get help with Georgia Medicaid prescription drug benefits" body="The contacts below connect you to your CMO's pharmacy member services line, DCH oversight, state regulators, free legal help, and patient assistance programs. For prior authorization help, contact your CMO first. For appeals, also consider contacting Georgia Legal Services Program." primary="Contact DCH Medicaid Member Services"}

• DCH Medicaid Member Services: contact DCH at medicaid.georgia.gov or call the number on your Medicaid card
• Amerigroup Pharmacy Member Services: call the member services number on your Amerigroup member ID card
• CareSource Pharmacy Member Services: call the member services number on your CareSource member ID card
• Peach State Pharmacy Member Services: call the member services number on your Peach State member ID card
• Wellpoint Pharmacy Member Services: call the member services number on your Wellpoint member ID card
• Georgia State Board of Pharmacy: contact via sbp.georgia.gov
• Georgia Department of Insurance (PBM complaints): contact via oci.georgia.gov
• Georgia Legal Services Program (free legal help): contact via georgialegalaid.org
• Atlanta Legal Aid Society: contact via atlantalegalaid.org
• HRSA 340B Office of Pharmacy Affairs: contact via hrsa.gov/opa
• Patient Advocate Foundation (cost assistance): contact via patientadvocate.org ::

Related Brevy guides on Georgia Medicaid

For more information on Georgia Medicaid topics related to PBM operations, see the following Brevy guides on brevy.com:

• Georgia Medicaid hub at /medicaid/georgia covers the full Georgia Medicaid program including eligibility, benefits, and CMO structure.
• Georgia Medicaid prescription drug coverage at /medicaid/georgia/prescription-drug-coverage covers the prescription drug benefit broadly.
• Georgia Medicaid prescription drug coverage and PDL at /medicaid/georgia/prescription-drug-coverage-and-pdl provides additional detail on the Preferred Drug List.
• Georgia Medicaid managed care plans at /medicaid/georgia/managed-care-plans covers the four Georgia Families CMOs.
• Georgia Medicaid FQHC and RHC coverage at /medicaid/georgia/fqhc-and-rhc-coverage covers 340B as it operates in FQHCs and RHCs.
• Georgia Medicaid behavioral health coverage at /medicaid/georgia/behavioral-health-coverage covers psychiatric medications and parity requirements.
• Georgia Medicaid appeals and fair hearings at /medicaid/georgia/appeals-and-fair-hearings provides the procedural detail for appealing denials.
• Georgia Medicaid how to apply at /medicaid/georgia/how-to-apply covers enrollment.

Find personalized help navigating Georgia Medicaid pharmacy benefits at brevy.com.

Disclaimer

This guide is provided for informational purposes only and does not constitute legal, medical, or financial advice. Federal and Georgia state PBM regulation, the Medicaid Drug Rebate Program, the 340B Drug Pricing Program, the Preferred Drug List, prior authorization criteria, and operational rules change frequently. Specific PBM subcontracting arrangements at the four CMOs can change as CMO corporate structures evolve. The information in this guide is current as of the date listed in the page metadata but may become outdated as regulations evolve. For specific questions about your Medicaid prescription drug coverage, prior authorization, appeals, or pharmacy network issues, contact your CMO pharmacy member services line, DCH Medicaid Member Services, the Georgia Department of Insurance, or a free legal advocacy organization such as Georgia Legal Services Program. The Centers for Medicare and Medicaid Services, the Georgia Department of Community Health, the Georgia Department of Insurance, and the Georgia State Board of Pharmacy are the authoritative sources for current rules and procedures.