Section 1.
Prohibits a pharmacy benefits manager (Manager), in new GS 58-58A-6, 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. Adds four new terms to GS 58-56A-1 (definitions provision of the pharmacy benefits management article in GS Chapter 58), including concession (a reduction in the cost of a prescription drug that a pharmacy benefits manager negotiates with a drug manufacturer or wholesale distributor. A concession includes fees, discounts, rebates, or other reductions in the cost to the pharmacy benefits manager. A concession does not include a bona fide service or administrative fee.) Directs a Manager, in GS 58-56A-3(c3), when calculating an insured's out-of-pocket cost for a covered prescription drug, to base the calculation on the net price of the prescription drug after taking into account all concessions associated with that prescription drug that the pharmacy benefits manager has received or will receive. Specifies that the current retail price cannot be used when calculating an insured's out-of-pocket cost for a prescription drug if the pharmacy benefits manager has received, is receiving, or will receive any concessions associated with that particular prescription drug.
Prevents a Manager from charging a pharmacy or pharmacist a fee related to the adjudication of a claim under GS 58-56-A4 (currently, a Manager can charge such a fee if certain conditions are met). Prohibits Managers from engaging in any of six listed practices, including basing pharmacy reimbursement on patient outcomes, scores, or metrics. Requires pharmacies and pharmacists to obtain a specialty pharmacy accreditation under the NC Pharmacy Practice Act when dispensing certain specialty drugs (as defined). Narrows the circumstances in which a claim may be retroactively denied or reduced, by disallowing retroactive denials or reductions when the adjustments are part of an attempt to limit overpayment recovery efforts by a Manager. Makes conforming changes.
Prohibits Managers, in GS 58-56A-15, from: (1) requiring multiple specialty pharmacy accreditations as a prerequisite for participation in a retail pharmacy network that dispenses specialty drugs; (2) from denying the right of any properly licensed pharmacist or pharmacy that has a specialty drug accreditation to participate in a retail pharmacy network that includes network participants that dispense specialty drugs on the same terms and conditions of other similarly situated participants in the network; and (3) from charging a pharmacist or pharmacy a fee related to participating in a retail pharmacy network. Makes a technical change.
Requires Managers, effective April 1, 2026, to submit quarterly reports under new GS 58-56A-22 on the four listed matters to the Insurance Commissioner. Designates the report information confidential and not subject to disclosure under State public records law. Starting August 1, 2026, requires the Commissioner to submit an annual report based on aggregate data received by the Managers. Requires posting of the report to the Department of Insurance (DOI) website. 
Amends GS 58-56A-25 by making Article 4C (Pharmacy Audit Rights) of GS Chapter 90 applicable to an audit of a pharmacy or pharmacist by a Manager, insurer, or third-party administrator and specifies that the provisions are enforceable by the Commissioner. 
Applies to contracts of insurance issued, renewed, or amended on or after October 1, 2025.
Allows the Commissioner to adopt temporary rules to implement these provisions.
Section 2.
Broadens the scope of GS 58-51-37 (concerning pharmacy of choice) by: (1) removing the exemptions for those entities that have 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) removing limitation that health benefit plans providing pharmacy services must be providing those services to State residents for the statute to apply. Adds new defined terms insured (any individual covered by a health benefit plan) and insurer. Amends defined terms health benefit plan and copayment. Adds an additional prohibited health benefit plan term preventing any such plan from imposing on an insured person 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. Removes the Commissioner’s power to impose civil penalties or restitution for violations of the statute under GS 58-2-70. Instead, specifies that a violation of this statute creates a civil cause of action for damages or injunctive relief in favor of any person or pharmacy aggrieved by the violation. Makes clarifying, technical, and organizational changes. Recodifies the term generic equivalent in GS 58-56A-3 (consumer protections) to GS 58-56A-1 (definitions provision of the article).
Further amends those definitions in GS 58-56A-1, as amended by Section 1, discussed above, to include new terms high-deductible health plan and Section 223. Makes technical and clarifying changes to term generic equivalent. Prevents a Manager from prohibiting an insured’s selection of a pharmacy or pharmacist with respect to any pharmacy or pharmacist that has agreed to participate as a provider in a health benefit plan's network according to the terms offered by the insurer. Makes other clarifying and conforming changes to GS 58-56A-3. Repeals GS 58-56A-50(c) (applying the provisions of GS 58-51-37 pertaining to pharmacy of choice to Managers with respect to 340B covered entities and 340B contract pharmacies). Applies to contracts of insurance issued, renewed, or amended on or after October 1, 2025.
Allows the Commissioner to adopt temporary rules to implement these provisions.
Section 3.
Narrows the scope of a pharmacy records audit to 25 total prescriptions, including refills (currently, 100 selected prescriptions) under GS 90-85-50 (pharmacy rights during audit by insurer or other entity responsible for payment of a benefits claim). Guarantees the pharmacy written notice of the basis of any additional claims triggered by the audit, including a specific description of any suspected fraud or abuse, at least 14 days prior to any additional audit. Makes technical changes. Requires, in new GS 90-85-52(a1) for the entity conducting the audit to provide the pharmacy with a summary of the total recoupment amount and the date on which the recoupment will be assessed, along with described documentation. Specifies that pharmacy audit rights apply to an audit of a pharmacy or pharmacist conducted by a Manager, insurer, or third-party administrator and is enforceable against these entities by the Commissioner. Applies to audits conducted on or after October 1, 2025. Allows the NC Board of Pharmacy to adopt temporary rules to implement these provisions.

Statutes affected:
Filed: 90-85.50, 90-85.52, 90-85.53