Includes whereas clauses. Enacts GS 58-3-222 as follows.

Establishes an annual process beginning in 2022 for determining the referenced rate, defined as the maximum rate established by the Commissioner of Insurance using the Wholesale Acquisition Cost and other pricing data, for referenced drugs, which are 250 of the most costly prescription drugs for members of the State Health Plan for Teachers and State Employees (SHP) for a particular calendar year. Provides for the State Treasurer to annually provide a list of the 250 costliest prescription drugs to the Commissioner, who must determine the referenced rate by comparing the wholesale acquisition cost to the cost on each of the four identified lists and formularies and calculated as the lowest cost among them, and annually create and publish a list on the Department of Insurance's website of the 250 referenced drugs and each drug's referenced rate for the next calendar year. Provides guidance for instances in which a particular referenced drug is not priced on the lists and formularies specified. 

Permits an ERISA plan (a health plan qualified under the Employee Retirement Income Security Act of 1974) to elect for its purchase of prescription drugs to be subject to the statute and notify the Commissioner in writing annually of its election. Prohibits health benefit plans that are not ERISA plans and participating ERISA plans from purchasing referenced drugs to be dispensed or delivered to an insured in the State for a cost higher than the referenced rate.

Directs the Commissioner to calculate annually the savings that are expected by imposing the referenced rate; requires the Superintendent of Insurance to consult with the State Treasurer and the Chair of the NC Board of Pharmacy. Requires State entities (as defined), health benefit plans that are not ERISA plans, and participating ERISA plans to use the savings derived from using the referenced rate to reduce costs to insured and annually report its savings to the Commissioner, as specified. 

Makes violations punishable by a fine of up to $1,000, with individual transactions considered separate violations. Provides for an affirmative defense to an enforcement action whereby a manufacturer or distributor refuses to negotiate in good faith a price for a referred drug within the referenced rate; requires reporting to the Attorney General.

Includes a severability clause. 

Applies to health benefit plan contracts entered into, renewed, or amended on or after October 1, 2021.