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HB 163

Prohibiting employment of unauthorized aliens.

2025 Regular Session Introduced by Bill Allemand and 16 co-sponsors

HB 163 bans spread pricing, uses net drug costs for patient cost sharing, and sets minimum pharmacy reimbursement to curb opaque PBMs and protect pharmacies.

H Did not Consider for Introduction
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Bill Summary · HB 163

HB 163 — Pharmacy Benefits Manager Provisions (2025) — Summary

Note: This summary addresses the version of HB 163 titled "Pharmacy Benefits Manager Provisions" (North Carolina General Assembly, 2025). It synthesizes the bill text (editions 1–3) and committee language provided.

Main purpose

To curb opaque PBM (pharmacy benefits manager) practices (notably spread pricing and undisclosed concessions), protect pharmacies (including specialty pharmacies) against unfair contracting and audit practices, ensure patient cost-sharing reflects net drug costs, and create uniform standards for how PBMs treat specialty pharmacy accreditation.

Key provisions and changes

  • Prohibition on spread pricing

    • PBMs may not charge an insurer a different price for a prescription drug than the amount the PBM directly or indirectly pays the dispensing pharmacy for that same claim (new G.S. 58‑56A‑6).

  • Definitions clarified/added

    • “Concession” (fees, discounts, rebates, etc.), “national average drug acquisition cost” (NADAC per CMS), “specialty drug,” “specialty pharmacy accreditation,” and related terms are defined to support enforcement.

  • Patient out‑of‑pocket calculations

    • When calculating patient cost sharing, PBMs must use the net price after accounting for all concessions the PBM has received or will receive for that drug (so current retail price cannot be used if concessions exist).

  • Minimum reimbursement and other payment restrictions

    • PBMs may not reimburse a pharmacy less than (a) the NADAC for the drug at the time of dispensing plus a professional dispensing fee (at least the Medicaid fee-for-service dispensing fee), and (b) the amount the PBM reimburses itself or an affiliate for the same drug or service.
    • PBMs are barred from receiving deductibles or copayments, imposing point-of-sale or retroactive fees, deriving revenue from pharmacies/insurees for PBM services, or diverting claims to non‑insurance adjudication platforms (discount/cash‑card programs).

  • Specialty pharmacy & network participation

    • PBMs cannot bar a properly licensed pharmacy from participating in a retail network on the same terms as similarly situated participants.
    • PBMs may not require multiple specialty accreditations as a prerequisite for network participation and must treat pharmacies accredited by nationally recognized bodies (URAC, ACHC, The Joint Commission, or similar) consistently.

  • Contract & policy limitations

    • PBMs may not use incorporated policy documents (provider manuals, audit procedures, etc.) to materially alter a pharmacy agreement or to retroactively change reimbursement, payment terms, or core contract definitions.

  • Audit and claims protections

    • Claims may not be retroactively denied or reduced after adjudication except under limited circumstances; adjustments intended to curb overpayment recovery abuse are expressly limited.

Who is affected

  • Pharmacies (community and specialty): gain stronger reimbursement floors, protections from certain fees and contracting tactics, and audit safeguards.
  • PBMs: face new restrictions on pricing models, revenue streams, auditing, and contracting practices.
  • Insurers/employers/health plans: may receive more price transparency from PBMs; premium/plan cost impacts depend on market adjustments.
  • Patients: could see out‑of‑pocket charges better aligned with net drug prices (potentially lower at point of sale when concessions exist).
  • Regulators/courts: may adjudicate disputes and oversee compliance; enforcement mechanisms (civil penalties, private causes of action) are not detailed in the excerpt.

Procedural status & timeline (from provided materials)

  • Introduced in the 2025 session (filed Feb 24, 2025 in NC materials).
  • Reported favorably in committee (multiple committee reports/editions).
  • Passed in the originating chamber (House) and transmitted to the Senate (status indicated as “Regular Message Sent to Senate” in the provided bill header).
  • For current legal status, effective dates, or any amendments adopted after transmittal, consult the official legislative website or the bill’s latest enrolled version.

Potential impacts and considerations

  • Greater transparency and potential redistribution of PBM revenue streams could raise payer costs in the short term if PBM retained margins are reduced; long‑term impacts depend on market responses.
  • Community and specialty pharmacies may benefit from improved cash flow and lower audit/clawback risk.
  • PBMs or other stakeholders may challenge some provisions, potentially prompting litigation or administrative rulemaking to clarify implementation.
  • Administrative burden for PBMs and payers to implement NADAC‑based reimbursement, net price calculations, and contract revisions.

For precise statutory language, enforcement mechanisms, and the bill’s final status (including any amendments), review the legislature’s official bill text and session records.

Compiled from official sources — confirm details with the bill’s official record.

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