House committee substitute to the 5th edition makes the following changes.

Part I.

Removes terms housing unit, independent pharmacy, pharmacy desert, rural, and urban from GS 58-51-37 (pertaining to pharmacy of choice). Removes exemptions to the statute’s bar of an insurer’s imposition of a monetary advantage as described. Prohibits an insurer from imposing upon an insured 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 the purchase of pharmacy services or products, including prescription drugs, from any pharmacy that is more costly or more restrictive than that which would be imposed upon the insured if the same services or products were purchased from either a mail-order pharmacy or any other pharmacy that is willing to provide the same services or products for the same cost and copayment as any mail-order service.

Part II.

Removes GS 58-56B-40 which would have provided financial penalties if Pharmacy Services Administrative Organization (PSAO) failed to comply with the provisions of new Article 56B of GS Chapter 58. Removes provisions specifying that PSAO’s have a duty of good faith and fair dealing to independent pharmacies in GS 58-56B-45. Makes technical changes to Part II’s effective date. Makes organizational changes.

Part III.

Adds generic equivalent, high-deductible health plan, national average drug acquisition cost, Section 223, specialty drug, and specialty pharmacy to the definitions in GS 58-56A-1 (pertaining to pharmacy benefits management), and removes independent pharmacy and pharmacy desert as defined terms. Removes provisions pertaining to pharmacy desert reporting requirements (GS 58-56A-23).  

Now prevents a pharmacy benefits manager (PBM) from reimbursing a pharmacy or pharmacist for a prescription drug in an amount less than the national average drug acquisition cost for the prescription drug or pharmacy service at the time the drug is administered or dispensed, plus a professional dispensing fee in GS 58-56A-4(g). (Previously, prevented a PBM contract from requiring directly or indirectly or through a pharmacy services administration organization, an independent pharmacy or any pharmacy in a pharmacy desert, to accept reimbursement for providing a covered prescription drug, device, or service at a rate less than the acquisition cost for the covered drug, device, or service.) Removes provisions designating violations of GS 58-56A-4(g) an unfair trade practice.

Enacts GS 58-56A-6 preventing a PBM from charging an insurer offering a health benefit plan a price for a prescription drug that differs from the amount the pharmacy benefits manager directly or indirectly pays the pharmacy or pharmacist for providing pharmacist services under that same health benefit plan. Applies to contracts entered into, renewed, or  amended on or after October 1, 2025. Makes conforming changes to instruction to the Department of Insurance (DOI) to makes rules to implement Part III. Makes conforming changes to the part’s effective date for specific sections.

Part IV.

Applies the consumer protections provisions of GS 58-3-128 to PBM’s when calculating an insured out-of-pocket cost for a covered drug in GS 58-56A-3 (consumer protections-PBM’s).  Removes requirement that a shipping charged be specifically agreed to by a health benefit plan or PBM as a requirement for imposing a shipping cost under GS 58-56A-3.

Prohibits, in GS 58-56A-15 a PBM from (1) requiring multiple specialty pharmacy accreditations as a prerequisite for participation in a retail pharmacy network that dispenses specialty drugs and excluding a specialty pharmacy from the right to participate in the network and (2) charging a pharmacist or pharmacy a fee related to participating in a retail pharmacy network. (Was, only required a PBM network to meet or exceed the Medicare Part D program standards for convenient access to network pharmacies under federal law.)

Part V.

Removes provision adding independent pharmacy to the defined terms of the NC Pharmacy Practice Act. Removes new GS 90-85.21E that would have allowed an independent pharmacy to decline or refill a prescription if the act would directly result in an unbearable cost to the independent pharmacy so long as it refers the patient to another equally convenient pharmacy as described.

Part VI.

Changes the scope of audits conducted for reasons other an identified problem in GS 58-50-405 to the lesser of (1) 0.1% of the number of total prescription fills processed through the pharmacy benefits manager for that pharmacy in a calendar year or (2) 50 prescription fills processed through the pharmacy benefits manager for that pharmacy in a calendar year (was, limited to 100 selected prescriptions). Now provides that, except in the case of an identified problem, the pharmacy is entitled to written notice provided at least 14 days prior to any audit of additional claims that details the basis for the review of additional claims, including a specific description of any suspected fraud or abuse. Makes a technical change.

Requires the auditing entity to provide a pharmacy with a summary describing the total recoupment, and the approximate date, within a seven-day window (was, no reference to seven-day window) in GS 58-50-410, as created by the act. 

Part VIII.

Removes amendments to GS 58-56A-3 specifying that GS 58-3-182 applies to PBM’s when calculating an insured’s out-of-pocket costs for a covered prescription drug. Makes organizational changes.

Part IX.

Directs the Department of Health and Human Services (DHHS) to adopt rules implement new Article 4D (Prescription Drug Transparency) to GS Chapter 90. Specifies that new Article 4D is effective January 1, 2026.