PBM Reform

 

Occasionally, NCAP receives questions from members regarding North Carolina PBM-related laws. The following resource compiles existing PBM statutes, organized by categories, for which inquiries are commonly made. In addition, the resource provides a direct link to the Department of Insurance portal for filing PBM-related complaints.

 

Contents

Consumer Protections

Anti-Gag Clause
     Section 4.1. § 58-56A-3. Pg. 10 

Prescription Cost Sharing
     Section 7.1. § 58-3-182. Pg. 16-17

Pharmacy of Choice
     Section 1.1. § 58-51-37. Pg. 1- 4 (c)(1)-(3) & (5)
          (e) Equal Contracting, Notice to Pharmacies, and Informing Patients
          (f) Equal Rebates and Marketing Incentives
     Section 4.2. § 58-56A-15. Pg. 10-11

HIPAA Responsibility for PBM Affiliates
     Section 6.1. § 58-56A-20.(a) Pg. 16

Access to Non-formulary and Restricted Access Prescription Drugs 
     § 58‑3‑221.

Anti-Steering and Incentivization
     Section 1.1. § 58-51-37. Pg. 1- 4
          (c)(4) & (6) Prohibition on Mail Order
          (d) Equal Patient Cost Sharing

Pharmacist and Pharmacy Protections 

Prescription Drug Transparency
     Section 8.(a) § 90-85.56.(a)-(d) Pg. 17-18 
          Required Notifications and Disclosures

PBM Reimbursement Disparities Between Affiliate and Non-Affiliate
     Section 6.1. § 58-56A-20.(b) Pg. 16

Network Adequacy and “Any Willing Provider”
     Section 4.2. § 58-56A-15.(c)(1)-(2) & (e) Pg. 10-11 

     Section 1.1. § 58-51-37.(a) & (f) Pg. 1- 4 

Health Benefit Plan Requirements
     Section 3.3. § 58-56A-55. Pg. 9 

Audits, Claims, and Appeals
     § 58-56A-5. 
     § 58-56A-4.(a)-(f)     
          Fees and Claims
     Section 3.2.(a) § 58-56A-4. is amended by adding new subsection (g) Pg. 9
          Reimbursement Below Acquisition Cost 
     Section 3.4. § 58-56A-21.(a)&(b) Pg. 9 section 3.4.   
          Duties Owed to Contracted Insurers
     § 90‑85.50.  is recodified as section 5.1. (§ 58-50-405.(a)-(b)) Pg. 12-14 
          Rights of a Pharmacy 
     § 90-85.52. is recodified as section 5.1.(b) & 5.2.(a) (§ 58-50-410.(a)-(i) & (j)) Pg. 14-16 
          Pharmacy Audit Recoupment 
     § 90‑85.50.(b) is recodified as section 5.1.(b) (§ 58-50-415.) Pg. 15
          Reversals of Approval
     § 90-85.51.  is recodified as section 5.1.(b) (§ 58-50-420.)  Pg. 15 
          Mandatory Appeals Process 
     § 90-85.53. is recodified as section 5.1.(b) (58-50-425.) Pg. 15 
          Applicability 

Pharmacy Rights to Mail/Ship Patient Medications
     § 58-56A-3.reads as rewritten b(1) 

Maximum Allowable Cost (MAC) Pricing
     § 58-56A-5. 

PBM Contracts
     Section 10.(a) § 135-49. Pg. 19

Contracts with 340B Covered Entities
     § 58-56A-50. 

Natural Disaster/State of Emergency 
     § 58-3.228.

Access to Non-formulary and Restricted Access Prescription Drugs
     § 58‑3‑221.

Reimbursement Rates in Medicaid Managed Care
     Section 11.(a) section 9D.19A. Of  S.L. 2021-180, as amended by S.L. 2022-74 Pg. 20 

Pharmacy Services Administration Organization (PSAO) 
     Section 2.1. § 58-56B-20. Pg. 6
          Prohibition on price discrimination
     Section 2.1. § 58-56B-30. Pg. 6 
          Ownership interests 
     Section 2.1. § 58-56B-35. Pg. 6-7 
          Appeals 
     Section 2.1. § 58-56B-40. Pg. 7 
          Penalties 

North Carolina Department of Insurance

Licensure Requirements for PBM
     § 58-56A-2.

Violations
     Section 5.2.(b) § 58-50-429.  Pg. 16 

Civil Penalties for Violations & Administrative Proceedings
     § 58-56A-30.

Reporting Requirements for Transparency 
     Section 3.1.(b) § 58-56A-22.  Pg. 8-9
     Section 3.5.(a) § 58-56A-6. Pg.  9-10  
          Spread Pricing 

Data Collection and Reporting Responsibilities of the Secretary of NC DHHS
     Section 8.(a) § 90-85.58. Pg. 18 

Penalty for Failure to Report (Manufacturers)
     Section 8.(a) § 90-85.57.   Pg. 18

Enforcement 
     § 58-56A-25. 

NC Board of Pharmacy Reporting Responsibility
     Section 9. § 90-85.42. Pg. 19 

File a complaint with the North Carolina Department of Insurance
Phone: 855-408-1212

Additional Resources

Statutory-related Definitions
     PBM Transparency, Fair Reimbursement, and Fiduciary Duties
          § 58-56A-1.
     Prescription Drug Transparency 
          § 90-85.55.  
     NC BOP Reporting - Pharmacy Size
          § 90-85.42. (NC BOP Reporting - Pharmacy Size)
     Pharmacy of Choice - Contract Provide/Co-Pay/Pharmacy Desert/etc.
          § 58-51-37. (Pharmacy of Choice - contract provider/pharmacy desert/co-payment/etc.)
     PSAOs
          § 58-56B-1. (PSAOs)
     Consumer Protections/Prescription Cost-Sharing
          § 58-3-182. (Consumer Protections/Prescription Cost-sharing)
     Audit Protections
          § 58-50-400. 
     Health Benefit Plan Applicability
          § 58-3-167.