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View NCGA Bill Details2023-2024 Session
House Bill 246 (Public) Filed Wednesday, March 1, 2023
Intro. by Sasser, Bell, Blackwell, Humphrey.

Status: Ref To Com On Rules and Operations of the Senate (Senate action) (May 1 2023)
H 246

Bill Summaries:

  • Summary date: Mar 1 2023 - View Summary

    Part I.

    Amends GS 58-56A-1 by adding and defining the following terms as they are used in Article 56A, Pharmacy Benefits Management, of GS Chapter 58: national average drug acquisition cost, specialty drug, and specialty pharmacy accreditation.

    Amends GS 58-56A-4 by deleting the provisions related to fees that may be charged by a pharmacy benefits manager for a fee relating to the adjudication of a claim, and instead replaces those provisions with the following. Prohibits a pharmacy benefits manager from charging a pharmacist or pharmacy a fee related to the adjudication of a claim. Prohibits a pharmacy benefits manager from: (1) reimbursing a pharmacy or pharmacist for a prescription drug or pharmacy service in an amount less than the national average drug acquisition cost for the prescription drug or pharmacy service at the time it is administered or dispensed, plus a professional dispensing fee (as defined); (2) reimbursing a pharmacy or pharmacist for a prescription drug or pharmacy service in an amount less than the amount the pharmacy benefits manager reimburses itself or an affiliate for the same prescription drug or pharmacy; (3) basing pharmacy reimbursement on patient outcomes, scores, or metrics; (4) imposing a point-of-sale or retroactive fee on a pharmacist, pharmacy, or insured; (5) deriving any revenue from a pharmacist, pharmacy, or insured in connection with performing pharmacy benefits management services; and (6) receiving deductibles or copayments. Provides that a pharmacy or pharmacist must not be prohibited by a pharmacy benefits manager from dispensing any specialty drug allowed to be dispensed under a license to practice pharmacy under Article 4A of GS Chapter 90 if the pharmacist or pharmacy obtains specialty pharmacy accreditation. Makes a conforming deletion. No longer allows the retroactive denial or reduction of a claim for pharmacist services after adjudication of the claim when the adjustments were part of an attempt to limit overpayment recovery efforts by a pharmacy benefits manager. Specifies that that the provisions of Article 4C, Pharmacy Audit Rights, of GS Chapter 90 apply to an audit of a pharmacy or pharmacist conducted by a pharmacy benefits manager, insurer, or third-party administrator and are enforceable by the Commissioner.

    Enacts new GS 58-56A-6 prohibiting a pharmacy benefits manager from charging an insurer offering a health benefit plan a price for prescription drugs that differs form the amount the manager pays the pharmacy or pharmacist for pharmacist services.

    Amends GS 58-56A-15 to prohibit a pharmacy benefits manager from (1) denying the right to any properly licensed pharmacist or pharmacy with specialty drug accreditation to participate in a retail pharmacy network that dispenses specialty drugs on the same terms and conditions of other similarly situated participants in the network or (2) requiring multiple specialty pharmacy accreditations as a prerequisite for participation in a retail pharmacy network that dispenses specialty drugs. Also prohibits a pharmacy benefits manager from charging a pharmacist or pharmacy a fee related to participation in a retail pharmacy network.

    Enacts new GS 58-56A-22 to require licensed pharmacy benefits managers to file a report quarterly, beginning April 1, 2025, that contains four specified items concerning aggregate wholesale acquisition costs for therapeutic categories of drugs, aggregate rebates for each health benefit plan, aggregate amount of fees and rebates received, and rebates from all manufacturers that were not passed on to clients. Makes the information in the report confidential and privileged and not a public record, not subject to subpoena, and not subject to discovery or admissible in evidence in a private civil action. Requires the Commission to annually, beginning August 1, 2025, to prepare a report based on the reported information and post the report on the Department of Insurance's website.

    Part II.

    Amends GS 58-51-37, pharmacy of choice, to no longer exclude from the statute's provisions (1) any entity that has its own facility; employs or contracts with physicians, pharmacists, nurses, and other health care personnel; and that dispenses prescription drugs from its own pharmacy to its employees and to enrollees of its health benefit plan and (2) a hospital or other health care facility licensed pursuant to GS Chapters 131E or 122C, when dispensing prescription drugs to its patients. Adds that the terms of a health benefit must not impose upon a beneficiary any copayment, amount of reimbursement, number of days of a drug supply for which reimbursement will be allowed, or any other payment or condition relating to purchasing pharmacy services, including prescription drugs, from any pharmacy that is more costly or more restrictive than that which would be imposed upon the beneficiary if those services were purchased from a mail-order pharmacy or any other pharmacy willing to provide the same services or products for the same cost and copayment as any mail order service.

    Amends GS 58-5A-3 by specifying that a pharmacy benefits manager must not prohibit an insured's selection of a pharmacy or pharmacist with respect to any pharmacy or pharmacist that has agreed to participate in the health benefit plan according to the insurer's terms. Amends the provision requiring that when calculating an insured's contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or other applicable cost-sharing requirement, the insurer or pharmacy benefits manager must include any amounts paid by the insured for prescriptions that meet the specified requirements, to provide that this does not apply to an insured covered by a high deductible health plan if its application would render the insured ineligible for a health savings account unless the insured has satisfied the minimum deductible or the prescription qualifies as preventative care.

    Repeals GS 58-56A-50(c), under which the provisions of GS 58-51-37 (Pharmacy of choice) apply to pharmacy benefits managers with respect to 340B covered entities and 340B contract pharmacies.

    Part III.

    Amends GS 90-85.50 to provide that whenever a managed care company, insurance company, third-party payer, or any entity that represents a responsible party conducts an audit of the records of a pharmacy, the pharmacy has a right to: (1) if an audit is conducted for a reason other than described in subdivision (6) (having a projection of an overpayment or underpayment based on either the number of patients served with a similar diagnosis or the number of similar prescription orders or refills for similar drugs), the audit is limited to 15 total (was, 100 selected), including refills (previously did not specify that refills were included) and (2) if an audit reveals the necessity for a review of additional claims, the pharmacy may request the audit be conducted on site (was, on site without a request needed) and adds that it is entitled to written notice of the basis of the claims, including a specific description of any suspected fraud or abuse, at least 14 days prior to any additional audit.

    Amends GS 90-85.52 to require the entity conducting an audit, before any recoupment, to provide the pharmacy with a summary describing the total recoupment amount and the date on which it will be assessed. Requires the summary to also include payment summaries or electronic remittance advices documenting any disputed funds, charges, or other penalties.

    Part IV.

    Applies to contracts issued, renewed, or amended on or after October 1, 2023.