North Carolina HB 163: Pharmacy Benefits Manager Provisions.

Bill Text

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 THE USE OF SPREAD PRICING 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 THE PROTECTIONS PROVIDED 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 MANAGERS AND ESTABLISH 11
UNIFORM STANDARDS FOR THE TREATMENT OF ACCREDITING 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 not 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 pharmacy 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 and 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 E