HB 534 – NC Pharmacy Benefits Manager Licensure Act

HB 534 – NC Pharmacy Benefits Manager Licensure Act

Primary Sponsors: Rep. Wayne Sasser (R-Stanly), Rep. Greg Murphy (R-Pitt), Rep. David Lewis (R-Harnett), Rep. John Bell (R-Wayne)

Bill Summary

This bill would establish standards and criteria for the regulation and licensure of pharmacy benefit managers. This bill provides claims processing services or other prescription drug or services for health benefit plans.

Licensure

The bill states that a person or organization could not operate as a pharmacy benefits manager in this State for health benefit plans without obtaining a license from the Commissioner of the Department of Insurance.

The bill states that the application fee will be $2,000, and the renewal fee will be $1,500.

Consumer Protections

The bill states that a pharmacy benefits manager shall not prohibit, restrict, or penalize a pharmacy or pharmacist from providing any of the following:

  • Disclosing to any insured any health information that the pharmacy/pharmacist deems appropriate within the pharmacists scope of practice
  • Discussing information regarding to the total cost for pharmacist services for a prescription or from selling a more affordable alternative to the insured if a cheaper option is available

The bill states that a pharmacy benefits manager shall not charge, or attempt to collect from, an insured copayment that exceeds the lesser of the following amounts:

  • The total submitted charges by the network pharmacy
  • The contracted copayment amount
  • The amount an individual would pay for a prescription drug if that individual was not insured and was paying cash for the prescription.

The bill states that an insured shall not be restricted from utilizing any in-network pharmacy.

Pharmacy and Pharmacist Protections

The bill states that a pharmacy benefits manager may only charge a reasonable fee or adjustment .

The bill states that a pharmacy benefit manager shall not engage in a practice of expressly driving out competition or financially injuring independent pharmacies.

The bill states that pharmacy benefits managers shall not require the use of mail order for filling prescriptions unless required to do so by the health benefit plan.

Maximum Allowable Cost Price

The bill states that a pharmacy benefits manager shall establish an administrative appeal procedure which a contracted pharmacy/pharmacist can appeal the provider’s reimbursement for the drug subject to the maximum allowable cost pricing if the reimbursement for the drug is less than the net amount that the network provider paid to the suppliers of the drug.

Data Sharing

The bill states that a pharmacy benefits manager that has an affiliate shall disclose to a health benefit plan, and any provider contracted under that plan, any difference between the amount paid to a pharmacy and the amount charged to the health benefit plan.

The bill states that a pharmacy benefits manager shall not transfer or share records containing patient and prescriber identifiable data to a PBM for any commercial purpose.

Bill Movement

This bill was filed on April 2, 2019.

 
 

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