NC S632

Pharmacy benefits managers (PBMs) must obtain a license from the North Carolina Department of Insurance, with an initial application fee of $2,000 and annual renewal fee of $1,500.

PBMs are prohibited from charging copayments exceeding the lesser of: total submitted charges, contracted copayment amount, or cash price; and cannot retroactively deny claims except for fraud, duplicate payment, unrendered services, or agreed adjustments.

Pharmacies and pharmacists cannot be prohibited from disclosing cost information, offering delivery services, discussing affordable alternatives, or participating in class action lawsuits; PBMs cannot require use of affiliated pharmacies or mandate mail order prescriptions.

Maximum allowable cost prices must be reviewed and adjusted at least every seven business days, with pharmacies able to appeal reimbursements within 10 calendar days if the reimbursement is less than their acquisition cost.

Violations subject PBMs to civil penalties of $100-$1,000 per day for maximum allowable cost violations and discretionary penalties for other violations, plus potential license revocation and court-ordered restitution to pharmacists or the Department.