Pharmacy Benefits Manager Provisions.

GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2025
H 3
HOUSE BILL 163
Committee Substitute Favorable 4/1/25
Committee Substitute #2 Favorable 4/15/25

Short Title: Pharmacy Benefits Manager Provisions. (Public)
Sponsors:
Referred to:
February 24, 2025
*H163-v-3*
A BILL TO BE ENTITLED 1
AN ACT TO REGULATE T HE USE OF SPREAD PRI CING AND CONCESSIONS BY 2
PHARMACY BENEFITS MANAGERS, TO ESTABLISH UNIFORM STANDARDS FOR 3
THE TREATMENT OF SPECIALTY PHARMACY ACCREDITATION BY PHARMACY 4
BENEFITS MANAGERS, TO CLARIFY THE RIGHT TO A PHARMACY OF CHOICE, 5
AND TO STRENGTHEN TH E PROTECTIONS PROVID ED TO PHARMACIES 6
DURING AUDITS. 7
The General Assembly of North Carolina enacts: 8
9
PART I. REGULATE THE USE OF SPREAD PRICING AND CONCESSIONS SUCH AS 10
FEES AND REBATES BY PHARMACY BENEFITS MA NAGERS A ND ESTABLISH 11
UNIFORM STANDARDS FO R THE TREATMENT OF A CCREDITING SPECIALTY 12
PHARMACIES BY PHARMACY BENEFITS MANAGERS 13
SECTION 1.1. Article 56A of Chapter 58 of the General Statutes is amended by 14
adding a new section to read: 15
"§ 58-56A-6. Protection against spread pricing. 16
A pharmacy benefits manager shall not charge an insurer offering a health benefit plan a price 17
for a prescription drug that differs from the amount the pharmacy benefits manager directly or 18
indirectly pays the pharmacy or pharmacist for providing pharmacist services under that same 19
health benefit plan." 20
SECTION 1.2.(a) G.S. 58-56A-1 reads as rewritten: 21
"§ 58-56A-1. Definitions. 22
The following definitions apply in this Article: 23
… 24
(4a) Concession. – A reduction in the cost of a prescription drug that a pharmacy 25
benefits manager negotiates with a drug manufacturer or wholesale 26
distributor. A concession includes fees, discounts, rebates, or other reductions 27
in the cost to the pharmacy benefits manager. A concession does n ot include 28
a bona fide service or administrative fee. 29
(4b) Reserved for future codification purposes. 30
(4c) Generic equivalent. – A drug that meets all of the following criteria: 31
a. Has an identical amount of the same active ingredients in the same 32
dosage form as a non-generic drug. 33
General Assembly Of North Carolina Session 2025
Page 2 House Bill 163-Third Edition
b. Meets applicable standards of strength, quality, and purity according 1
to the United States Pharmacopeia or other nationally recognized 2
compendium. 3
c. If administered in the same amount as a non -generic drug, provides 4
comparable therapeutic effects. 5
This term does not include a drug that is listed by the United States Food and 6
Drug Administration as having unresolved bioequivalence concerns 7
according to the Administration 's most recent publication of approved drug 8
products with therapeutic equivalence evaluations. 9
… 10
(5a) High-deductible health plan. – As defined under the Internal Revenue Code. 11
… 12
(9a) National average drug acquisition cost. – The publicly available, most current 13
pharmacy acquisition cost benchmark published by the Centers for Medicare 14
and Medicaid Services (CMS), which reflects the average price that retail 15
community pharmacies pay to acquire prescription drugs from wholesalers, 16
excluding rebates and discounts. 17
… 18
(16a) Section 223. – Section 223 of the Internal Revenue Code or its equivalent. 19
(16b) Specialty drug. – Either of the following prescription medications: 20
a. A medication that is subject to restricted distribution by the United 21
States Food and Drug Administration. 22
b. A medication used to treat complex or chronic conditions that requires 23
special handling, provider coordination, or patient education. 24
(16c) Specialty pharmacy. ‒ A pharmacy accredited as a specialty phar macy by a 25
nationally recognized, independent accrediting organization that evaluates a 26
pharmacy's compliance with quality, safety, and service standards for 27
handling, dispensing, and managing specialty drugs. The accreditation may be 28
issued by the Utilization Review Accreditation Commission (URAC), 29
Accreditation Commission for Health Care (ACHC), the Joint Commission, 30
their successors, or any similar nationally recognized accrediting 31
organization. 32
…." 33
SECTION 1.2.(b) G.S. 58-56A-4 reads as rewritten: 34
"§ 58-56A-4. Pharmacy and pharmacist protections. 35
(a) A pharmacy benefits manager may only charge fees or otherwise hold a pharmacy 36
responsible for a fee relating to the adjudication of a claim if the fee is reported on the remittance 37
advice of the adjudicated claim or is set out in contract between the pharmacy benefits manager 38
and the pharmacy. No fee or adjustment for the receipt and processing of a claim, or otherwise 39
related to the adjudication of a claim, shall be charged without a justification on the remittance 40
advice or as set out in contract an d agreed upon by the pharmacy or pharmacist for each 41
adjustment or fee. This section shall not apply with respect to claims under an employee benefit 42
plan under the Employee Retirement Income Security Act of 1974 or Medicare Part D. A 43
pharmacy benefits manager shall not ch arge a pharmacist or pharmacy a fee related to the 44
adjudication of a claim. 45
(a1) A pharmacy benefits manager shall not do any of the following: 46
(1) Reimburse a pharmacy or pharmacist for a prescription drug in an amount less 47
than the national average drug acquisition cost for the prescription drug or 48
pharmacy service at the time the drug is administered or dispensed, plus a 49
professional dispensing fee. For purposes of this sub section, a "professional 50
dispensing fee" means an amount equal to or higher than the fee -for-service 51
General Assembly Of North Carolina Session 2025
House Bill 163-Third Edition Page 3
professional drug dispensing fee calculated using the reimbursement 1
methodology described in the North Carolina Medicaid State Plan. 2
(2) Reimburse a pharmacy or pharmacist for a prescription drug or ph armacy 3
service in an amount less than the amount the pharmacy benefit s manager 4
reimburses itself or an affiliate for the same prescription drug or pharmacy. 5
(3) Base pharmacy reimbursement for prescription drugs on patient outcomes, 6
scores, or metrics. 7
(4) Impose a point -of-sale or retroactive fee on a pharmacist, pha rmacy, or 8
insured. 9
(5) Derive any revenue from a pharmacist, pharmacy, or insured in connection 10
with performing pharmacy benefits management services. 11
(6) Receive deductibles or copayments. 12
(7) Directly or indirectly divert, transfer, or otherwise redirect any prescription 13
drug claims submitted by a pharmacy or pharmacist to any third -party 14
discount card program, cash discount program, or any other non -insurance 15
adjudication platform. 16
(8) Use pharmacy benefits manager policy documents which are incorporated into 17
a pharmacy agreement, including , but not limited to , provider manuals, 18
administrative guidelines, operational policies, ancillary documents, claims 19
processing rules, and/or audit and comp liance procedures, to materially 20
change, alter, or modify the pharmacy agreement, to modify, limit, or negate 21
reimbursement rates, payment terms , or other financial obligations, or 22
introduce material changes to the definitions of brand and generic drugs, 23
claims adjudication, audit process, or contractual rights of the pharmacy or 24
pharmacist. 25
… 26
(c) A pharmacy or pharmacist shall not be prohibited by a pharmacy benefits manager 27
from dispensing any prescription drug, including specialty drugs dispensed by a credentialed and 28
accredited pharmacy, drug allowed to be dispensed under a license to practice pharmacy under 29
Article 4A of Chapter 90 of the General Statutes. 30
(c1) A pharmacy or pharmacist shall not be prohibited by a pharmacy benefits manager 31
from dispensing any specialty drug allowed to be dispensed under a license to practice pharmacy 32
under Article 4A of Chapter 90 of the General Statutes if the pharmacist or pharmacy is 33
accredited as a specialty pharmacy. 34
… 35
(e) A claim for pharmacist services may not be retroactively denied or reduced after 36
adjudication of the claim unless any of the following apply: 37
… 38
(5) The adjustments were part of an attempt to limit overpayment recovery efforts 39
by a pharmacy benefits manager. 40
… 41
(g) A pharmacy benefits manager may not prohibit a pharmacy or pharmacist that 42
dispenses a pharmaceutical product from, nor may a pharmacy benefit s manager penalize the 43
pharmacy or pharmacist for, informing an individual about the cost of the pharmaceutical 44
product, the amount in reimbursement that the pharmacy or pharmacist receives for dispensing 45
the pharmaceutical product, the cost and clinical ef ficacy of a less expensive alternative to the 46
pharmaceutical product, or any difference between the cost to the individual under the 47
individual's pharmacy benefits plan or program and the cost to the individual if the individual 48
purchases the pharmaceutical product without making a claim for benefits under the individual's 49
pharmacy benefits plan or program." 50
SECTION 1.2.(c) G.S. 58-56A-15 reads as rewritten: 51
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"§ 58-56A-15. Pharmacy benefits manager networks. 1
(a) A pharmacy benefits manager shall not deny t he right to of any properly licensed 2
pharmacist or pharmacy to participate in a retail pharmacy network on the same terms and 3
conditions of other similarly situated participants in the network. 4
(a1) A pharmacy benefits manager shall not require multiple specialty pharmacy 5
accreditations as a prerequisite for participation in a retail pharmacy network that dispenses 6
specialty drugs nor exclude a specialty pharmacy from the right to participate in the network. 7
… 8
(d) A pharmacy benefits manager shall not charge a pharmacist or pharmacy a fee related 9
to participation in a retail pharmacy network." 10
SECTION 1.3. Article 56A of Chapter 58 of the General Statutes is amended by 11
adding a new section to read: 12
"§ 58-56A-22. Reporting. 13
(a) Effective May 1, 2026, and quarterly thereafter, every pharmacy benefits manager 14
licensed in this State shall file a report with the Commissioner that contains all of the following 15
information for the applicable time period: 16
(1) The aggregate wholesale acquisition costs to the pharmacy benefits manager 17
from manufacturers or wholesale distributors for each therapeutic category of 18
drugs covered under each health benefit plan offered by all insurers that 19
contract with the pharmacy benefits manager, net of all concessions, direct or 20
indirect, from all sources. 21
(2) The aggregate amount of the concessions that the pharmacy benefits manager 22
received from all drug manufacturers or wholesale distribut ors for each 23
insurer contracting with the pharmacy benefits manager , detailed by each 24
health benefit plan offered by the insurer . In reporting the aggregate amount 25
of the rebates, the pharmacy benefits manager shall include any utilization 26
discounts it receives from a manufacturer or wholesale distributor. 27
(3) The aggregate amount of all concessions that the pharmacy benefits manager 28
received. 29
(4) All concessions received by the pharmacy benefits manager from all 30
manufacturers or wholesale distribut ors that were not passed on by the 31
pharmacy benefits manager to an insurer contracting with the pharmacy 32
benefits manager or other clients of the pharmacy benefits manager. 33
(b) The information contained in the report required by this section shall be confidential 34
by law and privileged, shall not be considered a public record under either G.S. 58-2-100 or 35
Chapter 132 of the General Statutes, shall not be subject to subpoena, and shall not be subject to 36
discovery or admissible into evidence in any private civil action. The Commissioner is authorized 37
to use this information in the furtherance of any regulatory or legal action brought as a part of 38
the Commissioner's official duties. 39
(c) Effective August 1, 2026, and annually thereafter, the Commissioner shall prepare a 40
report based on the information received under this section. The report shall aggregate data and 41
shall not contain information that would cause financial, competitive, or proprietary harm to any 42
individual pharmacy benefits manager. The Commissioner shall post the report required by this 43
subsection on the Department's website." 44
SECTION 1.4. This Part becomes effective October 1, 2025, and applies to contracts 45
issued, renewed, or amended on or after that date. 46
47
PART II. CLARIFY HEA LTH BENEFIT PLAN BEN EFICIARY'S RIGHT TO A 48
PHARMACY OF CHOICE A ND MAKE TECHNICAL CO RRECTIONS AND 49
UPDATES TO STATUTES DEALING WITH THESE CONSUMER PROTECTIONS 50
SECTION 2.1. G.S. 58-51-37 reads as rewritten: 51
General Assembly Of North Carolina Session 2025
House Bill 163-Third Edition Page 5
"§ 58-51-37. Pharmacy of choice. 1
(a) This section shall apply to all health benefit plans providing pharmaceutical services 2
benefits, including prescription drugs, to any resident of North Carolina. This section shall also 3
apply to insurance companies and health mainte nance organizations that provide or administer 4
coverages and benefits for prescription drugs. This section shall apply to pharmacy benefits 5
managers with respect to 340B covered entities and 340B contract pharmacies, as defined in 6
G.S. 58-56A-1. This secti on shall not apply to any entity that has its own facility, employs or 7
contracts with physicians, pharmacists, nurses, and other health care personnel, and that 8
dispenses prescription drugs from its own pharmacy to its employees and to enrollees of its health 9
benefit plan; provided, however, this section shall apply to an entity otherwise excluded that 10
contracts with an outside pharmacy or group of pharmacies to provide prescription drugs and 11
services. This section shall not apply to any federal program, cl inical trial program, hospital or 12
other health care facility licensed pursuant to Chapter 131E or Chapter 122C of the General 13
Statutes, when dispensing prescription drugs to its patients. 14
(b) As used Definitions. – The following definitions apply in this section: 15
(1) "Copayment" means a Copayment. – A type of cost sharing whereby insured 16
or covered persons requiring insureds to pay a specified predetermined 17
amount per unit of service with their the insurer paying the remainder of the 18
charge. The copayment is incurred at the time the service is used. The 19
copayment may be a fixed or variable amount. 20
(2) "Contract provider" means a Contract provider. – A pharmacy granted the 21
right to provide prescription drugs and pharmacy services according to the 22
terms of the insurer. 23
(3) "Health benefit plan" is as that term is Health benefit plan. – As defined in 24
G.S. 58-50-110(11).G.S. 58-3-167. 25
(4) "Insurer" means any entity that provides or offers a health benefit 26
plan.Insured. – Any individual covered by a health benefit plan. 27
(4a) Insurer. – As defined in G.S. 58-3-167. 28
(5) "Pharmacy" means a Pharmacy. – A pharmacy registered with the North 29
Carolina Board of Pharmacy. 30
(b1) Applicability. – This section applies to insurers offering health benefit plans that 31
include prescription drug or pharmacy benefits. This section shall also apply to pharmacy benefits 32
managers in the same way that it applies to insurers with respect to 340B covered entities and 33
340B contract pharma cies, as defined in G.S. 58-56A-1. This section d oes not apply to any 34
federal program or clinical trial program. 35
(c) Health Benefit Plan Terms. – The terms of a health benefit plan shall not:not do any 36
of the following: 37
(1) Prohibit or limit a resident of this State, who is eligible for reimbursement for 38
pharmacy services as a participant or beneficiary of a health benefit plan, an 39
insured, from selecting a pharmacy of his or her choice when the pharmacy 40
has agreed to participate in the health benefit plan according to the terms 41
offered by the insurer;insurer. 42
(2) Deny a pharmacy the opportunity to participate as a contract provider under a 43
health benefit plan if the pharmacy agrees to provide pharmacy services that 44
meet the terms and requirements, including terms of reimbursement, of the 45
insurer under a that health benefit plan, provided that if plan. If the pharmacy 46
is offered the opportunity to participate, participate as a contract provider, it 47
must participate or no provisions of G.S. 58-51-37 this section shall 48
apply;apply. 49
(3) Impose upon a beneficiary of pharmacy services under a health benefit plan 50
an insured any copayment, fee, or condition that is not equally imposed upon 51
General Assembly Of North Carolina Session 2025
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all beneficiaries insureds in the same benefit category, class, or copayment 1
level under the health benefit plan when receiv ing services from a contract 2
provider;provider. 3
(4) Impose a monetary advantage or penalty under a health benefit plan that 4
would affect a beneficiary's an insured 's choice of pharmacy. Monetary 5
advantage or penalty includes pharmacy, including a higher copayment, a 6
reduction in reimbursement for services, or the promotion of one participating 7
pharmacy over another by these methods. 8
(5) Reduce allowable reimbursement for pharmacy services to a beneficiary under 9
a health benefit plan an insured because the beneficiary insured selects a 10
pharmacy of his or her choice, so long as that pharmacy has enrolled with the 11
health benefit plan under the terms offered to all pharmacies in the plan 12
coverage area; orarea. 13
(6) Require a beneficiary, an insured, as a condition of payment or 14
reimbursement, to purchase pharmacy products or services, including 15
prescription drugs, exclusively through a mail-order pharmacy. 16
(7) Impose upon an insured any copayment, amount of reimbursement, number 17
of days of a drug supply f or which reimbursement will be allowed, or any 18
other payment or condition relating to the purchase of pharmacy services or 19
products, including prescription drugs, from any pharmacy that is more costly 20
or more restrictive than that which would be imposed up on the insured if the 21
same services or products were purchased from either a mail-order pharmacy 22
or any other pharmacy that is willing to provide the same services or products 23
for the same cost and copayment as any mail-order service. 24
(d) Use of Agent. – A pharmacy, by or through a pharmacist acting on its behalf as its 25
employee, agent, or owner, may not waive, discount, rebate, or distort a copayment of any 26
insurer, policy, or plan, insurer or health benefit plan or a beneficiary's an insured's coinsurance 27
portion of a prescription drug coverage or reimbursement and if of a prescription drug. If a 28
pharmacy, by or through a pharmacist's acting action on its behalf as its employee, agent agent, 29
or owner, provides a pharmacy service to an enrollee of a health benefit plan insured that meets 30
the terms and requirements of the insurer under a health benefit plan, then the pharmacy shall 31
provide its pharmacy services to all enrollees of individuals covered under that health benefit 32
plan on the same terms and requirements of the insurer. A violation of this subsection shall be is 33
a violation of the Pharmacy Practice Act subjecting the pharmacist as a licensee to disciplinary 34
authority of the North Carolina Board of Pharmacy pursuant to G.S. 90-85.38. 35
(e) Offer to Participate. – At least 60 days before the effective date of any health benefit 36
plan providing reimbursement to North Carolina residents coverage for prescription drugs, which 37
drugs that restricts pharmacy participation, the entity insurer providing the health benefit plan 38
shall notify, in writing, provide a written notification and offer to all pharmacies within the 39
geographical coverage area of the health benefit plan, and offer to the pharmacies plan the 40
opportunity to participate in the health benefit plan. All pharmacies in the geographical coverage 41
area of the plan shall be eligible to participate under identical reimbursement terms for providing 42
pharmacy services, including prescription drugs. The entity providing the health benefit plan 43
insurer shall, through reasonable means, on a timely basis, and on regular intervals in order to 44
effectuate the purposes of this section, inform the beneficiaries of the plan insureds of the names 45
and locations of pharmacies that are participating in the plan as providers of pharmacy services 46
and prescription drugs. Additionally, participating pharmacies shall be entitled to announce their 47
participation to their customers through a means acceptable to the pharmacy an d the entity 48
providing the health benefit plans. insurer. The pharmacy notification provisions of this section 49
shall not apply when an individual or group is enrolled, but when the plan enters a particular 50
county of the State. 51
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House Bill 163-Third Edition Page 7
(f) Rebates and Marketing Incentives. – If rebates or marketing incentives are allowed to 1
pharmacies or other dispensing entities providing pharmaceutical services or benefits under a 2
health benefit plan, these rebates or marketing incentives shall be offered on an equal basis to all 3
pharmacies and other dispensing entities providing services or benefits under a the health benefit 4
plan when pharmacy services, including prescription drugs, are purchased in the same volume 5
and under the same terms of payment. Nothing in this section shall prevent a pharmaceutical 6
manufacturer or wholesale distributor of pharmaceutical products from providing special prices, 7
marketing incentives, rebates, or discounts to different purchasers not prohibited by federal and 8
State antitrust laws. 9
(g) Any entity or insurer providing a health benefit plan is subject to G.S. 58-2-70. 10
Violations of This Section. – It shall be a violation of this section for any insurer to provide any 11
health benefit plan providing coverage for pharmaceutical services or products to residents of 12
this State that does not conform to the provisions of this section. A violation of this section shall 13
subject the entity providing a health benefit plan insurer to the sanctions of revocation, 14
suspension, or refusal to renew license in the discretion of the Commissioner pursuant to 15
G.S. 58-3-100. A violation of this section creates a civil cause of action for damages or injunctive 16
relief in favor of any person or pharmacy aggrieved by the violation. 17
(h) A violation of this section creates a civil cause of action for damages or injunctive 18
relief in favor of any person or pharmacy aggrieved by the violation. 19
(i) Approval by Commissioner. – The Commissioner shall not approve any health benefit 20
plan providing pharmaceutical services which that does not conform to this section. 21
(j) Provisions to the Contrary Void. – Any provision in a health benefit plan which is 22
executed, delivered, or renewed, or otherwise contracted for in this State that is contrary to any 23
provision of this section shall, to the extent of the conflict, be void. 24
(k) It shall be a violation of this section for any insurer or any person to provide any 25
health benefit plan providing for pharmaceutical services to residents of this State that does not 26
conform to the provisions of this section. 27
(l) Certain Lock-In Programs. – An insurer's use of a lock -in program developed 28
pursuant to G.S. 58-51-37.1 or G.S. 108A-68.2 is not a violation of this section." 29
SECTION 2.2. G.S. 58-56A-3 reads as rewritten: 30
"§ 58-56A-3. Consumer protections. 31
… 32
(b1) A pharmacy benefits manager shall not prohibit a pharmacist or pharmacy from 33
charging a minimal shipping and handling fee to the insured for a mailed or delivered prescription 34
if the pharmacist or pharmacy discloses all of the following to the insured before delivery: 35
(1) The fee will be charged. 36
(2) The fee may not be reimbursed by the health benefit plan, insurer, or pharmacy 37
benefits manager. 38
(3) The charge is specifically agreed to by the health benefit plan or pharmacy 39
benefits manager. 40
(c) A pharmacy benefits manager shall not charge, or attempt to collect from, an insured 41
a copayment that exceeds the total submitted charges by the network pharmacy. 42
(c1) When calculating an insured's contribution to any out -of-pocket maximum, 43
deductible, copayment, coinsurance, or other applicable cost-sharing requirement, the insurer or 44
pharmacy benefits manager shall include any amounts paid by the insured, or on the insured's 45
behalf, for a prescription that is either:either of the following: 46
(1) Without an AB-rated generic equivalent. 47
(2) With an AB-rated generic equivalent if the insured has obtained authorization 48
for the drug through any of the following: 49
a. Prior authorization from the insurer or pharmacy benefits manager. 50
b. A step therapy protocol. 51
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c. The exception or appeal process of the insurer or pharmacy benefits 1
manager. 2
This subsection shall not apply to an insured covered by a high deductible health plan, as that 3
term is defined in section 223 of the Internal Revenue Code, plan, if its application would render 4
the insured ineligible for a health savings account under section 223 unless (i) the insured has 5
satisfied the minimum deductible under section 223 or (ii) the prescription qualifies as preventive 6
care under section 223. 7
(c2) For purposes of this section, the term "generic equivalent" means a drug that has an 8
identical amount of the same active ingredients in the same dosage form; meets applicable 9
standards of strength, quality, and purity according to the United States Pharmaco peia or other 10
nationally recognized compendium; and which, if administered in the same amount, would 11
provide comparable therapeutic effects. The term "generic equivalent" does not include a drug 12
that is listed by the United States Food and Drug Administrat ion as having unresolved 13
bioequivalence concerns according to the Administration's most recent publication of approved 14
drug products with therapeutic equivalence evaluations. 15
(c3) When calculating an insured 's out-of-pocket cost for a covered prescription drug, a 16
pharmacy benefits manager shall base the calculation on the net price of the prescription drug 17
after taking into account all concessions associated with that prescription drug that the pharmacy 18
benefits manager has received or will receive. The cu rrent retail price shall not be used when 19
calculating an insured 's out-of-pocket cost for a prescription drug if the pharmacy benefits 20
manager has received, is receiving, or will receive any concessions associated with that particular 21
prescription drug. 22
(d) Any contract for the provision of a network to deliver health care services between a 23
pharmacy benefits manager and insurer shall be made available for review by the Department. 24
(e) Repealed by Session Laws 2021 -161, s. 1(b), effective October 1, 2021, a nd 25
applicable to any contracts entered into, renewed, or amended on or after that date. 26
(f) A pharmacy benefits manager shall not prohibit an insured's selection of a pharmacy 27
or pharmacist with respect to any pharmacy or pharmacist that has agreed to part icipate as a 28
provider in a health benefit plan's network according to the terms offered by the insurer." 29
SECTION 2.3. G.S. 58-56A-50(c) is repealed. 30
SECTION 2.4. This Part becomes effective October 1, 2025, and applies to contracts 31
issued, renewed, or amended on or after that date. 32
33
PART III. STRENGTHEN PHARMACY AUDIT PROTECTIONS 34
SECTION 3.1. G.S. 90-85.50 reads as rewritten: 35
"§ 90-85.50. Declaration of pharmacy rights during audit. 36
(a) The following definitions apply in this Article: 37
(1) "Pharmacy" means a Pharmacy. – A person or entity holding a valid pharmacy 38
permit pursuant to G.S. 90-85.21 or G.S. 90-85.21A. 39
(2) "Responsible party" means the Responsible party. – The entity responsible for 40
payment of claims for health care services other than (i) the individual to 41
whom the health care services were rendered or (ii) that individual's guardian 42
or legal representative. 43
(b) Notwithstanding any other provision of law, whenever a managed care company, 44
insurance company, third-party payer, or any entity that represents a responsible party conducts 45
an audit of the records of a pharmacy, the pharmacy has a right to all of the following: 46
… 47
(8) If an audit is conducted for a reason other than described in subdivision (6) of 48
this subsection, the audit is limited to 100 selected prescriptions. Unless the 49
audit is for reasons described in subdivision (6) of this subsection, the 50
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following audit restrictions shall apply to aud its conducted by a pharmacy 1
benefits manager: 2
a. A retail pharmacy may only be audited once per calendar quarter. 3
b. The audit is restricted to the lesser of (i) one -tenth of one percent 4
(0.1%) of the number of total prescription fills processed through the 5
pharmacy benefits manager for that retail pharmacy in a calendar year 6
or (ii) 50 prescription fills processed through the pharmacy benefits 7
manager for that pharmacy in a calendar year. 8
(9) If an audit reveals the necessity for a review of additional claims, to have then 9
the pharmacy may request the audit be conducted on site.site and is entitled to 10
written notice of the basis of the claims, including a specific description of 11
any suspected fraud or abuse, at least 14 days prior to any additional audit. 12
…." 13
SECTION 3.2. G.S. 90-85.52 reads as rewritten: 14
"§ 90-85.52. Pharmacy audit recoupments. 15
… 16
(a1) Prior to any recoupment, the entity conducting the audit shall provide the pharmacy 17
with a summary describing the total recoupment amount and the approximate date, within a 18
seven-day window, on which the recoupment will be ass essed. This summary shall be 19
accompanied by payment summaries or electronic remittance advices documenting any disputed 20
funds, charges, or other penalties. 21
…." 22
SECTION 3.3. G.S. 90-85.53 reads as rewritten: 23
"§ 90-85.53. Applicability. 24
(a) This Article does not apply to any audit, review, or investigation that involves alleged 25
Medicaid fraud, Medicaid abuse, insurance fraud, or other criminal fraud or misrepresentation. 26
(b) This Article applies to an audit of a pharmacy or pharmacist conducted by a pharmacy 27
benefits manager, insurer, or third -party administrator and is enforceable against these entities 28
by the Commissioner of Insurance under G.S. 58-56A-25." 29
SECTION 3.4. G.S. 58-56A-25 is amended by adding a new subsection to read: 30
"(d) The provisions of Article 4C of Chapter 90 of the General Statutes apply to an audit 31
of a pharmacy or pharmacist conducted by a pharmacy benefits manager, insurer, or third -party 32
administrator and are enforceable by the Commissioner." 33
SECTION 3.5. This Part becomes effective October 1, 2025, and applies to audits 34
initiated on or after that date. 35
36
PART IV. CLARIFYING "HEALTH BENEFIT PLAN" DOES NOT INCLUDE LOCAL 37
GOVERNMENT PLANS 38
SECTION 4. G.S. 58-3-167 reads as rewritten: 39
"§ 58-3-167. Applicability of acts of the General Assembly to health benefit plans. 40
(a) As used in this section: 41
(1) "Health benefit plan" means an accident and health insurance policy or 42
certificate; a nonprofit hospita l or medical service corporation contract; a 43
health maintenance organization subscriber contract; a plan provided by a 44
multiple employer welfare arrangement; or a plan provided by another benefit 45
arrangement, to the extent permitted by the Employee Retirem ent Income 46
Security Act of 1974, as amended, or by any waiver of or other exception to 47
that act provided under federal law or regulation. "Health benefit plan" does 48
not mean any plan implemented or administered by the North Carolina or 49
United States Depart ment of Health and Human Services, or any successor 50
agency, or its representatives. "Health benefit plan" does not mean any plan 51
General Assembly Of North Carolina Session 2025
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implemented or administered by the State Health Plan for Teachers and State 1
Employees. "Health benefit plan" does not mean any plan consisting of one or 2
more of any combination of benefits described in G.S. 58-68-25(b). "Health 3
benefit plan " does not mean any self -funded plan implemented or 4
administered by a local government. 5
…." 6
7
PART V. RULEMAKING AUTHORITY AND EFFECTIVE DATE 8
SECTION 5.1.(a) The Commissioner of Insurance may adopt temporary rules to 9
implement Part I and Part II of this act. 10
SECTION 5.1.(b) The North Carolina Board of Pharmacy may adopt temporary 11
rules to implement Part III of this act. 12
SECTION 5.2. Except as otherwise provided, this act is effective when it becomes 13
law. 14